Healthcare Provider Details

I. General information

NPI: 1013513167
Provider Name (Legal Business Name): AMANDA LYNN RAE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2020
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SAM PERRY BLVD
FREDERICKSBURG VA
22401-4453
US

IV. Provider business mailing address

1340 CENTRAL PARK BLVD STE 100
FREDERICKSBURG VA
22401-4940
US

V. Phone/Fax

Practice location:
  • Phone: 540-741-7614
  • Fax:
Mailing address:
  • Phone: 540-741-4254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024184271
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001449
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: