Basic Information
Provider Information | |||||||||
NPI: | 1851749881 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEHART | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | LEA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | COPE | ||||||||
OtherFirstName: | AMANDA | ||||||||
OtherMiddleName: | LEA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 3853 ROSECRANS ST | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921103115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6196928232 | ||||||||
FaxNumber: | 6195424060 | ||||||||
Practice Location | |||||||||
Address1: | 3853 ROSECRANS ST | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921103115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6196928232 | ||||||||
FaxNumber: | 6195424060 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2016 | ||||||||
LastUpdateDate: | 10/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | 828346 | CA | Y |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
No ID Information.