Provider Demographics
NPI:1841694486
Name:HANSEN, AMANDA (FNP-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 CARROLL ST
Mailing Address - Street 2:ROOM 2037
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266
Mailing Address - Country:US
Mailing Address - Phone:276-883-8062
Mailing Address - Fax:276-883-8064
Practice Address - Street 1:58 CARROLL ST
Practice Address - Street 2:ROOM 2037
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-883-8062
Practice Address - Fax:276-883-8064
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171702363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1841694486Medicaid
TNQ014850Medicaid
VAVVI284AMedicare PIN