Provider Demographics
NPI:1124309430
Name:GORMAN, AMANDA BRADY WATTERS (NP, RN)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:BRADY WATTERS
Last Name:GORMAN
Suffix:
Gender:F
Credentials:NP, RN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:BRADY
Other - Last Name:WATTERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, NP
Mailing Address - Street 1:2113 HIGHLAND RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:MD
Mailing Address - Zip Code:21131-1217
Mailing Address - Country:US
Mailing Address - Phone:917-567-5260
Mailing Address - Fax:844-364-2618
Practice Address - Street 1:8 HATTERS LN
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2332
Practice Address - Country:US
Practice Address - Phone:917-567-5260
Practice Address - Fax:844-364-2618
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR214487163W00000X, 363LP0200X
MD174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD092172600Medicaid