Provider Demographics
NPI:1356446678
Name:MILLER, AMANDA M (PA-C, RD, MMSC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA-C, RD, MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 COLLIER RD NW
Mailing Address - Street 2:SUITE 4055
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1796
Mailing Address - Country:US
Mailing Address - Phone:404-355-3200
Mailing Address - Fax:404-351-7548
Practice Address - Street 1:95 COLLIER RD NW
Practice Address - Street 2:SUITE 4055
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1796
Practice Address - Country:US
Practice Address - Phone:404-355-3200
Practice Address - Fax:404-351-7548
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007175363AM0700X, 363AS0400X
GA962527133V00000X
GALD002912133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I977275OtherMEDICARE