Provider Demographics
NPI:1003517244
Name:WALSH, AMANDA MICHELLE (APRN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:WALSH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 COUNTY ROAD 783
Mailing Address - Street 2:
Mailing Address - City:DOUGLASS
Mailing Address - State:TX
Mailing Address - Zip Code:75943-4240
Mailing Address - Country:US
Mailing Address - Phone:936-205-6353
Mailing Address - Fax:
Practice Address - Street 1:510 E COMMERCE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-4910
Practice Address - Country:US
Practice Address - Phone:903-535-9041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-14
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX807548163W00000X
TX1113044363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse