Basic Information
| Provider Information | |||||||||
| NPI: | 1891445698 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANGE | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUDSON | ||||||||
| OtherFirstName: | AMANDA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 861 CORONADO CENTER DR STE 131 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890523992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7257770414 | ||||||||
| FaxNumber: | 7025655027 | ||||||||
| Practice Location | |||||||||
| Address1: | 861 CORONADO CENTER DR STE 131 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890523992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7257770414 | ||||||||
| FaxNumber: | 7025655027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2022 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 851794 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 851794 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.