Basic Information
| Provider Information | |||||||||
| NPI: | 1174084669 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORADEL | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 751 BRIGGS HWY | ||||||||
| Address2: | |||||||||
| City: | ELLENVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124285501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182062000 | ||||||||
| FaxNumber: | 8453575039 | ||||||||
| Practice Location | |||||||||
| Address1: | 751 BRIGGS HWY | ||||||||
| Address2: | |||||||||
| City: | ELLENVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124285501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182062000 | ||||||||
| FaxNumber: | 8453575039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2019 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 307195 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.