Basic Information
| Provider Information | |||||||||
| NPI: | 1710265715 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODFREY | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | M T | ||||||||
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| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | TAMM | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 35 S MOUNTAIN BLVD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN TOP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187071122 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 35 S MOUNTAIN BLVD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN TOP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187071122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704745978 | ||||||||
| FaxNumber: | 5704745485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2011 | ||||||||
| LastUpdateDate: | 08/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2650 | WV | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | OS016918 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.