Provider Demographics
NPI:1659836914
Name:VANDERWALL, AMY ELIZABETH (CRNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:VANDERWALL
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ELIZABETH
Other - Last Name:SINNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:
Practice Address - Street 1:12560 STATE ROUTE 405
Practice Address - Street 2:
Practice Address - City:WATSONTOWN
Practice Address - State:PA
Practice Address - Zip Code:17777-8525
Practice Address - Country:US
Practice Address - Phone:570-538-2501
Practice Address - Fax:570-538-3227
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-31
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN630439163W00000X
PASP020400363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty