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General NPI Number Information
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NPI Number | 1063916419
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Entity Type | Individual
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Provider Name | AMANDA BERRY
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Gender | Female
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Dates
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Enumeration Date | 03/21/2018
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Last Update Date | 01/06/2023
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Provider Practice Location Address
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Address Line | MIMOSA AT GORDON AVENUE
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City | THOMASVILLE
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State | GA
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Zip | 31792
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Country | US
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Telephone | 386-697-9386
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Fax |
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Provider Business Mailing Address
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Address Line | 106 MOSS TRL
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City | THOMASVILLE
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State | GA
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Zip | 31792-1670
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 90517
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License Number State | GA
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