Healthcare Provider Details

I. General information

NPI: 1629576483
Provider Name (Legal Business Name): AMANDA FORTNER MITCHELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2018
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 S 4TH ST
GADSDEN AL
35901-5216
US

IV. Provider business mailing address

507 S 4TH ST
GADSDEN AL
35901-5216
US

V. Phone/Fax

Practice location:
  • Phone: 256-547-7417
  • Fax: 256-547-7414
Mailing address:
  • Phone: 256-547-7417
  • Fax: 888-207-3468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA1328
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: