Healthcare Provider Details

I. General information

NPI: 1043138613
Provider Name (Legal Business Name): AMANDA ELLENBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

654 COUNTY FARM RD
DUBLIN GA
31021-1799
US

IV. Provider business mailing address

205 BEAVER RUN DR
DUBLIN GA
31021-3863
US

V. Phone/Fax

Practice location:
  • Phone: 478-272-2051
  • Fax:
Mailing address:
  • Phone: 478-272-2051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN298574
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: