Basic Information
| Provider Information | |||||||||
| NPI: | 1528121670 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMOS | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TANNER | ||||||||
| OtherFirstName: | PATRICIA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 90 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457012301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405933682 | ||||||||
| FaxNumber: | 7405945642 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 FARSON ST UNIT 110 | ||||||||
| Address2: | |||||||||
| City: | BELPRE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457141067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404238095 | ||||||||
| FaxNumber: | 7404238096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 01/29/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0807X | ANCC #348954-02 | OH | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent | 163WP0809X | ANCC #30373371-01 | OH | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | 0963444 | 05 | OH | MEDICAID | MA1104583 | 01 | OH | DEA | OTHER |