Healthcare Provider Details

I. General information

NPI: 1578148441
Provider Name (Legal Business Name): AMANDA JUANITA HARMON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA JUANITA HARMON-JENKINS FNP

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 01/27/2026
Certification Date: 01/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SINGLETON RIDGE RD
CONWAY SC
29526-9142
US

IV. Provider business mailing address

300 SINGLETON RIDGE RD
CONWAY SC
29526-9142
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-7111
  • Fax:
Mailing address:
  • Phone: 843-347-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209029146
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209029146
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number24655
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN24655
License Number StateSC
# 5
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71017431A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: