Provider Demographics
NPI:1215403258
Name:CARLSON, AMANDA SUE (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:SUE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:SUE
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16 SECRETARIAT CIR
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5261
Mailing Address - Country:US
Mailing Address - Phone:616-780-7354
Mailing Address - Fax:
Practice Address - Street 1:2130 S 21ST ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-3401
Practice Address - Country:US
Practice Address - Phone:215-925-3566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP018141363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily