Healthcare Provider Details

I. General information

NPI: 1770970873
Provider Name (Legal Business Name): AMANDA C IVEY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 VILLAGE HARBOR DR
LAKE WYLIE SC
29710-9092
US

IV. Provider business mailing address

1200 VILLAGE HARBOR DR
LAKE WYLIE SC
29710-9092
US

V. Phone/Fax

Practice location:
  • Phone: 803-631-2858
  • Fax: 803-631-2862
Mailing address:
  • Phone: 803-631-2858
  • Fax: 803-631-2862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19257
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5008474
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: