Provider Demographics
NPI:1790220143
Name:DAVIS, AMANDA BLAKE (APRN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BLAKE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:RICHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2125 PARKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-7491
Mailing Address - Country:US
Mailing Address - Phone:479-226-0979
Mailing Address - Fax:479-242-2889
Practice Address - Street 1:3416 OLD GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5462
Practice Address - Country:US
Practice Address - Phone:479-242-2888
Practice Address - Fax:479-242-2889
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK118856363LF0000X
ARA0053338363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily