Provider Demographics
NPI:1447096565
Name:PORTER, AMANDA WILSON (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:WILSON
Last Name:PORTER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 WALTHALL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23834-5869
Mailing Address - Country:US
Mailing Address - Phone:804-317-2803
Mailing Address - Fax:
Practice Address - Street 1:1701 WALTHALL CREEK DR
Practice Address - Street 2:
Practice Address - City:SOUTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23834-5869
Practice Address - Country:US
Practice Address - Phone:804-317-2803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024190653363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily