Healthcare Provider Details

I. General information

NPI: 1255738332
Provider Name (Legal Business Name): AMANDA M BUSCHBACH CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA M KELLY CRNP

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 UNIVERSITY HOSPITAL DRIVE MASTIN PROFESSIONAL BUILDING SUITE 102
MOBILE AL
36617-2238
US

IV. Provider business mailing address

PO BOX 746450
ATLANTA GA
30374-6450
US

V. Phone/Fax

Practice location:
  • Phone: 251-470-5890
  • Fax: 251-471-7925
Mailing address:
  • Phone: 866-401-3057
  • Fax: 318-868-6430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-119193
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: