Provider Demographics
NPI:1417295601
Name:LAUDERBACK, AMANDA MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:LAUDERBACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MICHELLE
Other - Last Name:BICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:275 COLLIER RD NW STE 100C
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1700
Mailing Address - Country:US
Mailing Address - Phone:404-355-0320
Mailing Address - Fax:404-351-0909
Practice Address - Street 1:275 COLLIER RD NW STE 100C
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1700
Practice Address - Country:US
Practice Address - Phone:404-355-0320
Practice Address - Fax:404-351-0909
Is Sole Proprietor?:No
Enumeration Date:2013-01-22
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN186980363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN186980OtherMEDICAL LICENSE
GA003131811AOtherMEDICAID