Provider Demographics
NPI:1114621810
Name:THACKER, AMANDA LEE (FNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:THACKER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:224-D CORNWALL ST., NW
Mailing Address - Street 2:SUITE 403
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:19450 DEERFIELD AVENUE, SUITE 200
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-6821
Practice Address - Country:US
Practice Address - Phone:703-844-8380
Practice Address - Fax:703-263-8393
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185322363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017651500001Medicaid
VA1114621810Medicaid