Individual
DR. AMANDA LEANNE MOORE-ELCYZYN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
O.D.
Contact information
Practice address
113 W CARPENTER ST, BENTON, AR 72015-3317
(501) 778-2363
(501) 778-5329
Mailing address
1926 W STATE ST, BOISE, ID 83702-3957
(208) 336-2020
(208) 384-5677
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
2566
AR
152W00000X
Optometrist
Primary
ODP-100499
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
161893722
—
AR
01
—
49956
MEDICARE #
AR
Enumeration date
06/29/2006
Last updated
09/09/2020
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