Provider Demographics
NPI:1710632922
Name:BAKER, AMANDA BROOKE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BROOKE
Last Name:BAKER
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 1:1508 MILITARY CUTOFF RD STE 203
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-5730
Mailing Address - Country:US
Mailing Address - Phone:910-679-4312
Mailing Address - Fax:
Practice Address - Street 1:1508 MILITARY CUTOFF RD STE 203
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-5730
Practice Address - Country:US
Practice Address - Phone:910-679-4312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5015766363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner