Basic Information
| Provider Information | |||||||||
| NPI: | 1093113490 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIDD | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LUSK | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | ACNP-AG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1906 BELLEVIEW AVE SE | ||||||||
| Address2: | PO BOX 13367 | ||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409817000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1906 BELLEVIEW AVE SE | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409817000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2014 | ||||||||
| LastUpdateDate: | 12/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0001199884 | VA | N | Nursing Service Providers | Registered Nurse | 363LA2100X | 0024172026 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2200X | 0024172026 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 0024172026 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.