=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336948470
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA DANIELLE POLING APRN FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2025
-----------------------------------------------------
Last Update Date | 10/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1543 COUNTRY CLUB RD # A
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26554-1306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-363-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4055 VALLEY VIEW LN STE 700
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75244-5045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-838-2417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 122138
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------