Provider Demographics
NPI:1073109708
Name:MADDOX, AMANDA JEAN (FNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:MADDOX
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 703
Mailing Address - Street 2:
Mailing Address - City:SUMMERDALE
Mailing Address - State:AL
Mailing Address - Zip Code:36580-0703
Mailing Address - Country:US
Mailing Address - Phone:251-989-9400
Mailing Address - Fax:
Practice Address - Street 1:511 STATE HIGHWAY 59 N
Practice Address - Street 2:
Practice Address - City:SUMMERDALE
Practice Address - State:AL
Practice Address - Zip Code:36580-3686
Practice Address - Country:US
Practice Address - Phone:251-989-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-150202207Q00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine