Provider Demographics
NPI:1972139095
Name:WORTMAN, AMANDA (FNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WORTMAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MERCURY ST
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-5672
Mailing Address - Country:US
Mailing Address - Phone:605-939-9577
Mailing Address - Fax:
Practice Address - Street 1:24276 166TH ST, AIRPORT RD
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625-1012
Practice Address - Country:US
Practice Address - Phone:605-964-7724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001742363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily