Provider Demographics
NPI:1306943931
Name:WADDELL, AMANDA (APRN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WADDELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:PENDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:104 S FRONT AVE
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-1614
Mailing Address - Country:US
Mailing Address - Phone:606-886-8572
Mailing Address - Fax:606-886-4433
Practice Address - Street 1:104 S FRONT AVE
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-1614
Practice Address - Country:US
Practice Address - Phone:606-886-8572
Practice Address - Fax:606-886-4433
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003330363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3003330OtherSTATE NP LICENSE
KY78004652Medicaid
000000236830OtherBCBS PROVIDER NUMBER
KY78004652Medicaid
000000236830OtherBCBS PROVIDER NUMBER
0601317Medicare UPIN
KY500020515Medicare PIN