Provider Demographics
NPI:1043765720
Name:RAYNOR, AMANDA J (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:J
Last Name:RAYNOR
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:1045 SOUTHCREST DRIVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6113
Mailing Address - Country:US
Mailing Address - Phone:770-507-2212
Mailing Address - Fax:770-507-2213
Practice Address - Street 1:1045 SOUTHCREST DRIVE
Practice Address - Street 2:SUITE 110
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6113
Practice Address - Country:US
Practice Address - Phone:770-507-2212
Practice Address - Fax:770-507-2213
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN232150363LP0200X
GARN23215363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics