Basic Information
| Provider Information | |||||||||
| NPI: | 1821252800 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOVOLD | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LEA | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1520 WHITNEY CT | ||||||||
| Address2: | CENTRACARE CLINIC-HEARTLAND FAMILY MEDICINE | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567031899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202511775 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1520 WHITNEY CT | ||||||||
| Address2: | CENTRACARE CLINIC-HEARTLAND FAMILY MEDICINE | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567031899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202511775 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2008 | ||||||||
| LastUpdateDate: | 08/26/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 51987 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | ENROLLED | 05 | MN | MEDICAID | ENROLLED | 05 | IA | MEDICAID |