Provider Demographics
NPI:1104216639
Name:SHAW, AMANDA ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:SHAW
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 1:495 CHARLES HARDY PKWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-5723
Mailing Address - Country:US
Mailing Address - Phone:770-445-2128
Mailing Address - Fax:
Practice Address - Street 1:495 CHARLES HARDY PKWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-5723
Practice Address - Country:US
Practice Address - Phone:770-445-2128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN210233363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily