Provider Demographics
NPI:1770815730
Name:WALTHER, AMANDA S (CRNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:WALTHER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:S
Other - Last Name:MULVIHILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-8639
Mailing Address - Fax:
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-8639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR176495363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD962462-01 & 02OtherBLUE CROSS/BLUE SHIELD
MD419790900Medicaid
MDS062-0383OtherBLUE CROSS/BLUE SHIELD - REGIONAL
MD189858Y3WMedicare PIN
MDS062-0383OtherBLUE CROSS/BLUE SHIELD - REGIONAL