Healthcare Provider Details

I. General information

NPI: 1174939219
Provider Name (Legal Business Name): AMANDA U. GREEN DNP,FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 10/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1064 GARDNER RD STE 105-106
CHARLESTON SC
29407-5768
US

IV. Provider business mailing address

1064 GARDNER RD STE 105
CHARLESTON SC
29407-5711
US

V. Phone/Fax

Practice location:
  • Phone: 854-429-1175
  • Fax: 843-685-9467
Mailing address:
  • Phone: 854-429-1175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number217075
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number22248
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: