Healthcare Provider Details

I. General information

NPI: 1235048984
Provider Name (Legal Business Name): AMANDA NICOLE RAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

41 MCGOWAN LN NE
LUDOWICI GA
31316-5720
US

IV. Provider business mailing address

41 MCGOWAN LN NE
LUDOWICI GA
31316-5720
US

V. Phone/Fax

Practice location:
  • Phone: 912-294-3126
  • Fax:
Mailing address:
  • Phone: 912-294-3126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberRN239964
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: