Provider Demographics
NPI:1225212186
Name:CORNWELL, AMANDA BROOKE (PAA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BROOKE
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:PAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1448 GROVE PARK DR
Mailing Address - Street 2:APT 1401
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-1594
Mailing Address - Country:US
Mailing Address - Phone:912-224-2403
Mailing Address - Fax:
Practice Address - Street 1:11705 MERCY BLVD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1711
Practice Address - Country:US
Practice Address - Phone:912-819-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5183367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant