=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366140444
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA JO WENSON FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2023
-----------------------------------------------------
Last Update Date | 10/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6667 VERNON WOODS DR STE B40
-----------------------------------------------------
City | SANDY SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-3227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-968-9642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6203 PROVIDENCE CLUB DR
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-3698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-478-5695
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN249658
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN249658
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------