Healthcare Provider Details

I. General information

NPI: 1053195339
Provider Name (Legal Business Name): AMANDA LOUISE NUSBAUM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193 RECURVE LN
MARTINSBURG WV
25403-5402
US

IV. Provider business mailing address

193 RECURVE LN
MARTINSBURG WV
25403-5402
US

V. Phone/Fax

Practice location:
  • Phone: 301-524-6368
  • Fax:
Mailing address:
  • Phone: 301-524-6368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAC008421
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number103962
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: