Provider Demographics
NPI:1457132359
Name:IRWIN, AMANDA LACE (FNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LACE
Last Name:IRWIN
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 1:6514 SULGAR RD
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15851-2830
Mailing Address - Country:US
Mailing Address - Phone:814-591-5046
Mailing Address - Fax:
Practice Address - Street 1:6514 SULGAR RD
Practice Address - Street 2:
Practice Address - City:REYNOLDSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15851-2830
Practice Address - Country:US
Practice Address - Phone:814-591-5046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP028212363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily