Provider Demographics
NPI:1972126142
Name:ALLISTON, AMY FAY (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:FAY
Last Name:ALLISTON
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308B S MAIN ST STE 221
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-1744
Mailing Address - Country:US
Mailing Address - Phone:434-808-9453
Mailing Address - Fax:
Practice Address - Street 1:11507 S LOWELL RD
Practice Address - Street 2:
Practice Address - City:BAHAMA
Practice Address - State:NC
Practice Address - Zip Code:27503-8778
Practice Address - Country:US
Practice Address - Phone:434-808-9453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-22
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024186591363LP0808X
VAL-88133163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Multi-Specialty