Healthcare Provider Details

I. General information

NPI: 1073710646
Provider Name (Legal Business Name): AMANDA KAUFFMANN NGUYEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 DALLAS HWY SUITE 206
VILLA RICA GA
30180-1264
US

IV. Provider business mailing address

119 AMBULANCE DRIVE SUITE 202
CARROLLTON GA
30117
US

V. Phone/Fax

Practice location:
  • Phone: 770-456-3265
  • Fax:
Mailing address:
  • Phone: 770-838-8640
  • Fax: 770-838-8650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number64424
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number64424
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberRTP002369
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: