Provider Demographics
NPI:1447701388
Name:SANDERSON, AMANDA MICHELLE (APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MICHELLE
Other - Last Name:LITTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN, FNP-C
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:
Practice Address - Street 1:4610 KANAWHA AVE SW STE 401
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1367
Practice Address - Country:US
Practice Address - Phone:304-768-7368
Practice Address - Fax:304-768-1829
Is Sole Proprietor?:No
Enumeration Date:2016-10-15
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN72002-NP-C363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810024049 (GROUP)Medicaid
WV1447701388 (THSPP)Medicaid
WV1447701388 (THSPP)Medicaid
WVWV7205B441Medicare PIN