Basic Information
| Provider Information | |||||||||
| NPI: | 1093932212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAMOND | ||||||||
| FirstName: | AMANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 1ST AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581031802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012344036 | ||||||||
| FaxNumber: | 7012344160 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 1ST AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581031802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012344036 | ||||||||
| FaxNumber: | 7012344160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 01/18/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0600X | LP00224 | RI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | 10863 | ND | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1093932212 | 05 | MN | MEDICAID | 14766 | 05 | ND | MEDICAID |