Provider Demographics
NPI:1053897645
Name:PADILLA MARQUEZ, AMANDA RAE (NP-C)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:RAE
Last Name:PADILLA MARQUEZ
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-2930
Mailing Address - Fax:704-316-2938
Practice Address - Street 1:15825 BALLANTYNE MEDICAL PL STE 220
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-4790
Practice Address - Country:US
Practice Address - Phone:704-316-2930
Practice Address - Fax:704-316-2938
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22057363LF0000X
NC5017371363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily