Provider Demographics
NPI:1508394792
Name:ANDERSON, AMANDA DIANE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:DIANE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:DIANE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30 W RAMPART ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-8846
Mailing Address - Country:US
Mailing Address - Phone:317-421-2012
Mailing Address - Fax:
Practice Address - Street 1:2451 INTELLIPLEX DR STE 240
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-8581
Practice Address - Country:US
Practice Address - Phone:317-398-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007255A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner