Healthcare Provider Details

I. General information

NPI: 1700857059
Provider Name (Legal Business Name): AMANDA FAIRCLOTH WARD CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E MARSHALL ST ANESTHESIOLOGY CRNA
RICHMOND VA
23298-5051
US

IV. Provider business mailing address

PO BOX 91734
RICHMOND VA
23291-1734
US

V. Phone/Fax

Practice location:
  • Phone: 804-628-6990
  • Fax: 804-628-6932
Mailing address:
  • Phone: 804-628-6990
  • Fax: 804-628-6932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number557126
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024167211
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: