Provider Demographics
NPI:1164088977
Name:TISON, AMANDA FAYE (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:FAYE
Last Name:TISON
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:FAYE
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:72 BOLINGVIEW RD
Mailing Address - Street 2:
Mailing Address - City:JULIETTE
Mailing Address - State:GA
Mailing Address - Zip Code:31046-3932
Mailing Address - Country:US
Mailing Address - Phone:904-507-1221
Mailing Address - Fax:
Practice Address - Street 1:4837 BILL GARDNER PKWY STE B
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-3734
Practice Address - Country:US
Practice Address - Phone:678-800-1602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11002465363LF0000X
GAGAA-NP000337363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily