Provider Demographics
NPI:1144710518
Name:BRINSON, AMANDA JO MARIE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO MARIE
Last Name:BRINSON
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 1:59 6TH ST SE
Mailing Address - Street 2:
Mailing Address - City:LINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47441-1914
Mailing Address - Country:US
Mailing Address - Phone:812-798-7502
Mailing Address - Fax:
Practice Address - Street 1:1210 N 1000 W
Practice Address - Street 2:
Practice Address - City:LINTON
Practice Address - State:IN
Practice Address - Zip Code:47441-5013
Practice Address - Country:US
Practice Address - Phone:812-847-4481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-11
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28184504A163W00000X
IN71008401A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300019338Medicaid