Provider Demographics
NPI:1043321540
Name:SWAN, AMANDA MARIE (APRN, WHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:MARIE
Last Name:SWAN
Suffix:
Gender:F
Credentials:APRN, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 HARMUND PL
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1209
Mailing Address - Country:US
Mailing Address - Phone:860-670-6626
Mailing Address - Fax:
Practice Address - Street 1:49 WELLES ST STE 207
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4205
Practice Address - Country:US
Practice Address - Phone:860-325-2679
Practice Address - Fax:860-316-4064
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003762363LA2200X, 363LW0102X
NY420809363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT363LW0102XMedicaid