Provider Demographics
NPI:1801360086
Name:NUCKOLS, AMANDA (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NUCKOLS
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CLAYTON ST
Mailing Address - Street 2:
Mailing Address - City:WALBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43465-1404
Mailing Address - Country:US
Mailing Address - Phone:419-280-1828
Mailing Address - Fax:
Practice Address - Street 1:5308 HARROUN RD STE 55
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2174
Practice Address - Country:US
Practice Address - Phone:419-824-6599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.022931363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner