Healthcare Provider Details

I. General information

NPI: 1366140444
Provider Name (Legal Business Name): AMANDA JO WENSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6667 VERNON WOODS DR STE B40
SANDY SPRINGS GA
30328-3227
US

IV. Provider business mailing address

6203 PROVIDENCE CLUB DR
MABLETON GA
30126-3698
US

V. Phone/Fax

Practice location:
  • Phone: 404-968-9642
  • Fax:
Mailing address:
  • Phone: 678-478-5695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN249658
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN249658
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: