Healthcare Provider Details

I. General information

NPI: 1225234941
Provider Name (Legal Business Name): AMANDA MOORE R.N
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1087 OLD COURTHOUSE RD
SALUDA VA
23149-3068
US

IV. Provider business mailing address

1087 OLD COURTHOUSE RD
SALUDA VA
23149-3068
US

V. Phone/Fax

Practice location:
  • Phone: 804-832-6024
  • Fax: 804-758-0573
Mailing address:
  • Phone: 804-832-6024
  • Fax: 804-758-0573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001200421
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: