Provider Demographics
NPI:1215996962
Name:BALTIERRA, AMANDA J (FNP-BC)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:J
Last Name:BALTIERRA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 112
Mailing Address - Street 2:180 GRAFTON LANE
Mailing Address - City:BERRYVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22611-0112
Mailing Address - Country:US
Mailing Address - Phone:540-955-2400
Mailing Address - Fax:540-955-9765
Practice Address - Street 1:180 GRAFTON LN
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:VA
Practice Address - Zip Code:22611-2576
Practice Address - Country:US
Practice Address - Phone:540-955-2400
Practice Address - Fax:540-955-9765
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167997363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001726Medicaid
WVBA6032481Medicare ID - Type Unspecified
WV3810001726Medicaid