Provider Demographics
NPI:1649432477
Name:HALTIWANGER, AMANDA T (FNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:T
Last Name:HALTIWANGER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:TEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 630
Mailing Address - Street 2:600 N WHEELER AVE
Mailing Address - City:PROSPERITY
Mailing Address - State:SC
Mailing Address - Zip Code:29127-0630
Mailing Address - Country:US
Mailing Address - Phone:803-364-4852
Mailing Address - Fax:803-364-2014
Practice Address - Street 1:600 N WHEELER AVE
Practice Address - Street 2:
Practice Address - City:PROSPERITY
Practice Address - State:SC
Practice Address - Zip Code:29127-8400
Practice Address - Country:US
Practice Address - Phone:803-364-4852
Practice Address - Fax:803-364-2014
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPRN3585363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA27983093OtherMEDICARE PTAN
SCNP1242Medicaid