Healthcare Provider Details

I. General information

NPI: 1962854364
Provider Name (Legal Business Name): AMANDA ELIZABETH SALLE FULTON NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA ELISABETH SALLE NP-C

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11402 ANDERSON RD SUITE A
GREENVILLE SC
29611-7557
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-631-2799
  • Fax: 864-522-1215
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20332
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: