Provider Demographics
NPI:1295235331
Name:WHITAKER, AMANDA SHAWN (FNP-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SHAWN
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 HIGHWAY 5 N STE 10
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-3013
Mailing Address - Country:US
Mailing Address - Phone:870-232-0900
Mailing Address - Fax:870-232-0888
Practice Address - Street 1:230 HIGHWAY 5 N STE 10
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3013
Practice Address - Country:US
Practice Address - Phone:870-232-0900
Practice Address - Fax:870-232-0888
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902479363LF0000X
ARA005997363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5EA99OtherBLUE CROSS BLUE SHIELD OF ARKANSAS