Healthcare Provider Details

I. General information

NPI: 1194503722
Provider Name (Legal Business Name): AMANDA BOULOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2023
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1371 CHURCH STREET EXT NE SUITE 200
MARIETTA GA
30060-7913
US

IV. Provider business mailing address

1551 JANMAR RD
SNELLVILLE GA
30078-5606
US

V. Phone/Fax

Practice location:
  • Phone: 678-481-0579
  • Fax:
Mailing address:
  • Phone: 470-579-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number12976
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: