Provider Demographics
NPI:1346845096
Name:NOLD, AMANDA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:NOLD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 WIND TREE CV
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2974
Mailing Address - Country:US
Mailing Address - Phone:570-903-4683
Mailing Address - Fax:
Practice Address - Street 1:270 E COURT AVE
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-2304
Practice Address - Country:US
Practice Address - Phone:731-645-7932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16972084P0800X, 363A00000X
TN5112363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry