Provider Demographics
NPI:1023741543
Name:CARROLL, AMANDA ALEISHA (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ALEISHA
Last Name:CARROLL
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 N HILLS DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25387-1229
Mailing Address - Country:US
Mailing Address - Phone:304-542-8321
Mailing Address - Fax:
Practice Address - Street 1:1400 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9202
Practice Address - Country:US
Practice Address - Phone:304-757-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV111497363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care