Provider Demographics
NPI:1780081018
Name:NORTHERN, AMANDA MICHELLE (NP-C)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MICHELLE
Last Name:NORTHERN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:FALES
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3600 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3236
Mailing Address - Country:US
Mailing Address - Phone:757-215-3100
Mailing Address - Fax:757-398-9263
Practice Address - Street 1:3600 HIGH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3236
Practice Address - Country:US
Practice Address - Phone:757-215-3100
Practice Address - Fax:757-398-9263
Is Sole Proprietor?:No
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172143363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner