Provider Demographics
NPI:1245536408
Name:WAKIM, AMANDA PATRICIA (MSN,FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:PATRICIA
Last Name:WAKIM
Suffix:
Gender:F
Credentials:MSN,FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 16TH STREET
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003
Mailing Address - Country:US
Mailing Address - Phone:304-243-6410
Mailing Address - Fax:304-243-6411
Practice Address - Street 1:58 16TH STREET
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003
Practice Address - Country:US
Practice Address - Phone:304-243-6410
Practice Address - Fax:304-243-6411
Is Sole Proprietor?:No
Enumeration Date:2011-02-07
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV38366363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
2010009362OtherANCC CERTIFICATION NUMBER
38366OtherWV RN LICENSE NUMBER
OH0063534Medicaid
RN.287505OtherOHIO BOARD OF NURSING LICENSE NUMBER