Provider Demographics
NPI:1144651019
Name:RUST, AMANDA DAWN
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DAWN
Last Name:RUST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4909 SHELBURNE STREET
Mailing Address - Street 2:COMMUNITY OPTIONS
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503
Mailing Address - Country:US
Mailing Address - Phone:701-223-2417
Mailing Address - Fax:
Practice Address - Street 1:4909 SHELBURNE STREET
Practice Address - Street 2:COMMUNITY OPTIONS
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503
Practice Address - Country:US
Practice Address - Phone:701-223-2417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND171M00000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver