Provider Demographics
NPI:1942258074
Name:WOODRUFF, AMANDA S (NP, FNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:WOODRUFF
Suffix:
Gender:F
Credentials:NP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 HARRISON AVE
Mailing Address - Street 2:YACC BN-C7
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4001
Mailing Address - Country:US
Mailing Address - Phone:617-414-5405
Mailing Address - Fax:617-414-6031
Practice Address - Street 1:732 HARRISON AVE
Practice Address - Street 2:PRESTON, 3RD FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2309
Practice Address - Country:US
Practice Address - Phone:617-638-7490
Practice Address - Fax:617-414-8742
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226423363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0702226Medicaid
MA0702226Medicaid
MAQ23808Medicare UPIN
MAUX7389Medicare PIN