Healthcare Provider Details

I. General information

NPI: 1114621810
Provider Name (Legal Business Name): AMANDA LEE THACKER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19450 DEERFIELD AVENUE, SUITE 200
LEESBURG VA
20176-6821
US

IV. Provider business mailing address

224-D CORNWALL ST., NW SUITE 403
LEESBURG VA
20176-2704
US

V. Phone/Fax

Practice location:
  • Phone: 703-844-8380
  • Fax: 703-263-8393
Mailing address:
  • Phone: 703-737-6010
  • Fax: 703-443-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024185322
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: