MEDICARE: MS. AMANDA FRANCES LEE AGNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	RN216926	GA

General Provider Information

NPI Number	:	1558750752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AMANDA FRANCES LEE AGNP

Provider Business Mailing Address
First Line	:	5416 FOREST FALLS DR
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-3441
Country	:	US
Telephone Number	:	678-859-6013
Fax Number	:

Provider Business Practice Location Address
First Line	:	5416 FOREST FALLS DR
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-3441
Country	:	US
Telephone Number	:	678-859-6013
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2015
Last Update Date	:	04/16/2015

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