Provider Demographics
NPI:1114652369
Name:GILDERSLEEVE, AMANDA (NP-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GILDERSLEEVE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 PINE ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-4628
Mailing Address - Country:US
Mailing Address - Phone:971-246-9594
Mailing Address - Fax:
Practice Address - Street 1:1095 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1203
Practice Address - Country:US
Practice Address - Phone:503-767-3226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202210764NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily