Basic Information
Provider Information | |||||||||
NPI: | 1174040919 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RYNDA | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | KAY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DNP, CNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1237 PIONEER CT | ||||||||
Address2: |   | ||||||||
City: | SHAKOPEE | ||||||||
State: | MN | ||||||||
PostalCode: | 553793465 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9522398335 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 347 SMITH AVE N STE 203 | ||||||||
Address2: |   | ||||||||
City: | SAINT PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 551022388 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512417733 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2017 | ||||||||
LastUpdateDate: | 03/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 5370 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.