Provider Demographics
NPI:1154815736
Name:KNISLEY, AMANDA JOY
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JOY
Last Name:KNISLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:844 WILLARD ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON COURT HOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43160-2157
Mailing Address - Country:US
Mailing Address - Phone:740-463-4006
Mailing Address - Fax:
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2664
Practice Address - Country:US
Practice Address - Phone:614-722-9102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF04180325363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner