Healthcare Provider Details

I. General information

NPI: 1629537634
Provider Name (Legal Business Name): AMANDA VALLEN HEAD CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 04/19/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5211 HIGHWAY 278 NE
COVINGTON GA
30014-2671
US

IV. Provider business mailing address

2041 BURNING BUSH LN
CONYERS GA
30094-1120
US

V. Phone/Fax

Practice location:
  • Phone: 770-787-7444
  • Fax: 770-787-5050
Mailing address:
  • Phone: 678-735-0524
  • Fax: 770-787-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberRN102177
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN181771
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: