Provider Demographics
NPI:1497024327
Name:MCGILLIAN, AMANDA (PNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MCGILLIAN
Suffix:
Gender:F
Credentials:PNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3045 PENNSYLVANIA AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-3770
Mailing Address - Country:US
Mailing Address - Phone:304-723-4000
Mailing Address - Fax:304-723-4003
Practice Address - Street 1:3045 PENNSYLVANIA AVE STE 3
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-3770
Practice Address - Country:US
Practice Address - Phone:304-723-4000
Practice Address - Fax:304-723-4003
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV73677363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics