Healthcare Provider Details

I. General information

NPI: 1942417092
Provider Name (Legal Business Name): AMANDA KAY ANDERSON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4218 HIGHWAY 31 SOUTH
DECATUR AL
35603
US

IV. Provider business mailing address

434 E PIKE RD
FALKVILLE AL
35622-5109
US

V. Phone/Fax

Practice location:
  • Phone: 256-560-2248
  • Fax: 256-560-2249
Mailing address:
  • Phone: 256-560-2248
  • Fax: 256-560-2249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1027668
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: