Provider Demographics
NPI:1063706638
Name:LAVALLEY, AMANDA D (CRNA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:D
Last Name:LAVALLEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 W ARLINGTON BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3770
Mailing Address - Country:US
Mailing Address - Phone:252-752-2140
Mailing Address - Fax:252-689-6502
Practice Address - Street 1:2485 HEMBY LN
Practice Address - Street 2:SUITE A
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834
Practice Address - Country:US
Practice Address - Phone:252-752-2140
Practice Address - Fax:252-689-6502
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC202019163W00000X
NC87169367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP01042929OtherRAILROAD MEDICARE
NC1063706638OtherTRICARE
NC8054132Medicaid
NCQ36978AMedicare PIN