Healthcare Provider Details

I. General information

NPI: 1902511108
Provider Name (Legal Business Name): AMANDA GRACE BEVERLY AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 VINECREST CT # 1000
GREENWOOD SC
29646-8031
US

IV. Provider business mailing address

1601 GREENE ST
COLUMBIA SC
29208-4001
US

V. Phone/Fax

Practice location:
  • Phone: 864-725-3350
  • Fax: 864-725-3351
Mailing address:
  • Phone: 803-777-7412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number28004
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: