Healthcare Provider Details

I. General information

NPI: 1194565515
Provider Name (Legal Business Name): AMANDA LYNN WHITEHEAD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 LONGTOWN RD
COLUMBIA SC
29229-8550
US

IV. Provider business mailing address

324 AVENSONG TRL
ELGIN SC
29045-7141
US

V. Phone/Fax

Practice location:
  • Phone: 803-865-2122
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPN.29187
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberAPN.29187
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.29187
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: