Provider Demographics
NPI:1083226757
Name:HARRISON, AMY NICOLE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 FRED HALL RD
Mailing Address - Street 2:
Mailing Address - City:IVEY
Mailing Address - State:GA
Mailing Address - Zip Code:31031-2400
Mailing Address - Country:US
Mailing Address - Phone:478-979-0811
Mailing Address - Fax:
Practice Address - Street 1:620 S JEFFERSON ST SE
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-4006
Practice Address - Country:US
Practice Address - Phone:478-979-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-23
Last Update Date:2020-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide