Provider Demographics
NPI:1194004358
Name:TRUESDALE, AMANDA GOLSON
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:GOLSON
Last Name:TRUESDALE
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 1:5518 STONELEIGH CT
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-3433
Mailing Address - Country:US
Mailing Address - Phone:404-542-7999
Mailing Address - Fax:
Practice Address - Street 1:5518 STONELEIGH CT
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-3433
Practice Address - Country:US
Practice Address - Phone:404-542-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024176418347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle