Provider Demographics
NPI:1265023964
Name:ROBERTSON, AMANDA LONG (DNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LONG
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 2ND AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-7887
Mailing Address - Country:US
Mailing Address - Phone:843-572-4840
Mailing Address - Fax:
Practice Address - Street 1:2001 2ND AVE
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-7887
Practice Address - Country:US
Practice Address - Phone:843-572-4840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAG01210008363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner