Basic Information
| Provider Information | |||||||||
| NPI: | 1851644371 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENARY | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | JOHANNA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AARON | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | JOHANNA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 612 PALOMINO DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954015409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074843411 | ||||||||
| FaxNumber: | 7075767845 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954014282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075760818 | ||||||||
| FaxNumber: | 7075767845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2012 | ||||||||
| LastUpdateDate: | 10/22/2012 | ||||||||
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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 | 167G00000X | PT36689 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.