Provider Demographics
NPI:1619347853
Name:FLEENOR, AMANDA GRACE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRACE
Last Name:FLEENOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1583 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4317
Mailing Address - Country:US
Mailing Address - Phone:276-781-2090
Mailing Address - Fax:276-781-0866
Practice Address - Street 1:1583 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4317
Practice Address - Country:US
Practice Address - Phone:276-781-2090
Practice Address - Fax:276-781-0866
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005093363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant