Healthcare Provider Details

I. General information

NPI: 1043670201
Provider Name (Legal Business Name): AMANDA DERBY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 07/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

3100 SPRING FOREST RD SUITE 130
RALEIGH NC
27616-2880
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-3100
  • Fax:
Mailing address:
  • Phone: 919-882-0795
  • Fax: 919-873-9821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number282890
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number109837
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: