Provider Demographics
NPI:1720235203
Name:STANLEY, AMANDA A
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:A
Last Name:STANLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13706 APPLING LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-8314
Mailing Address - Country:US
Mailing Address - Phone:704-504-3154
Mailing Address - Fax:
Practice Address - Street 1:10628 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8407
Practice Address - Country:US
Practice Address - Phone:704-667-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC080544367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNAN907Medicaid
NC8053533Medicaid
SCNAN907Medicaid