Provider Demographics
NPI:1245411537
Name:REZBA, AMANDA JO (NP-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:REZBA
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 1:1115 BOULDERS PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-560-5595
Mailing Address - Fax:804-560-9029
Practice Address - Street 1:1115 BOULDERS PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23225-4067
Practice Address - Country:US
Practice Address - Phone:804-320-1339
Practice Address - Fax:804-330-5829
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167583363LF0000X
VA0001199728363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1245411537Medicaid
P00703382OtherMEDICARE RR
VA0603180002Medicare NSC
VA1245411537Medicaid