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General NPI Number Information
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NPI Number | 1164088977
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Entity Type | Individual
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Provider Name | AMANDA FAYE TISON APRN, FNP-C
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Gender | Female
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Dates
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Enumeration Date | 05/16/2019
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Last Update Date | 12/02/2021
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Provider Practice Location Address
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Address Line | 4837 BILL GARDNER PKWY STE B
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City | LOCUST GROVE
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State | GA
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Zip | 30248-3734
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Country | US
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Telephone | 678-800-1602
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Fax |
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Provider Business Mailing Address
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Address Line | 72 BOLINGVIEW RD
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City | JULIETTE
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State | GA
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Zip | 31046-3932
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Country | US
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Telephone | 904-507-1221
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 11002465
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | GAA-NP000337
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License Number State | GA
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