Healthcare Provider Details

I. General information

NPI: 1821417312
Provider Name (Legal Business Name): AMANDA COBB RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 UNIVERSITY RDG
GREENVILLE SC
29601-4712
US

IV. Provider business mailing address

604 SHADED ACRE CT
PELZER SC
29669-8956
US

V. Phone/Fax

Practice location:
  • Phone: 864-372-3195
  • Fax:
Mailing address:
  • Phone: 864-372-3195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number75905
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: