Provider Demographics
NPI:1023551603
Name:DAUGHERTY, AMANDA (FNP)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:791 FORT CHISWELL RD
Mailing Address - Street 2:
Mailing Address - City:FORT CHISWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24360-4139
Mailing Address - Country:US
Mailing Address - Phone:276-637-6641
Mailing Address - Fax:
Practice Address - Street 1:791 FORT CHISWELL RD
Practice Address - Street 2:
Practice Address - City:FORT CHISWELL
Practice Address - State:VA
Practice Address - Zip Code:24360-4139
Practice Address - Country:US
Practice Address - Phone:276-637-6641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-30
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174197363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily