Healthcare Provider Details

I. General information

NPI: 1699174417
Provider Name (Legal Business Name): AMBER WILLIAMS BANTA MSN, RN, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E BROAD ST
RICHMOND VA
23219-1930
US

IV. Provider business mailing address

PO BOX 780125
PHILADELPHIA PA
19178-0125
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-2467
  • Fax: 804-628-5852
Mailing address:
  • Phone: 804-922-4844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5007095
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024187003
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: