Provider Demographics
NPI:1649767773
Name:STREET, AMANDA BAIRD
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:BAIRD
Last Name:STREET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 748613
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15195 HEATHCOTE BLVD
Practice Address - Street 2:
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169-6242
Practice Address - Country:US
Practice Address - Phone:571-261-3529
Practice Address - Fax:703-361-1811
Is Sole Proprietor?:No
Enumeration Date:2018-04-14
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0024176366363L00000X
VA0024176366363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner