Provider Demographics
NPI:1104157346
Name:ANDERSON, AMANDA A (CNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:A
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:DEPT L3210
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43260-3210
Mailing Address - Country:US
Mailing Address - Phone:614-265-2921
Mailing Address - Fax:614-262-7074
Practice Address - Street 1:3705 OLENTANGY RIVER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3467
Practice Address - Country:US
Practice Address - Phone:614-262-6772
Practice Address - Fax:614-262-0435
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10329-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3028566Medicaid
BANP34301Medicare PIN