Provider Demographics
NPI:1649744384
Name:GILLENWATER, AMANDA L (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:GILLENWATER
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 PEMBERTON CV
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-5514
Mailing Address - Country:US
Mailing Address - Phone:731-394-1145
Mailing Address - Fax:844-374-0233
Practice Address - Street 1:2159 DOGWOOD RIDGE RD
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-9044
Practice Address - Country:US
Practice Address - Phone:731-394-1145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.454549163W00000X
OHAPRN.CNP.0027743363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0331807Medicaid