Provider Demographics
NPI:1295253581
Name:HUXTABLE, AMANDA MICHELLE (AGPCNP-C)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MICHELLE
Last Name:HUXTABLE
Suffix:
Gender:F
Credentials:AGPCNP-C
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:MICHELLE
Other - Last Name:HEEP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:540 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119-1964
Mailing Address - Country:US
Mailing Address - Phone:314-346-0808
Mailing Address - Fax:
Practice Address - Street 1:12303 DE PAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2512
Practice Address - Country:US
Practice Address - Phone:314-344-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017008669363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner