Healthcare Provider Details

I. General information

NPI: 1710170899
Provider Name (Legal Business Name): AMANDA MARIE PANCHAME NPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 CANTON ROAD
MARIETTA GA
30060
US

IV. Provider business mailing address

702 CANTON ROAD
MARIETTA GA
30060
US

V. Phone/Fax

Practice location:
  • Phone: 770-428-4486
  • Fax: 770-425-6005
Mailing address:
  • Phone: 770-428-4486
  • Fax: 770-425-6005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN146197
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: