Provider Demographics
NPI:1659133924
Name:WADE, AMANDA KAY (NP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAY
Last Name:WADE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:KAY
Other - Last Name:LENWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7979 N SHADELAND AVE STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2042
Practice Address - Country:US
Practice Address - Phone:317-621-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28189264A163W00000X
IN71015476A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300093159Medicaid