Provider Demographics
NPI:1427038470
Name:AMAZON, JODY L (NP)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:L
Last Name:AMAZON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 FOUNTAIN DR STE 220
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-7022
Mailing Address - Country:US
Mailing Address - Phone:678-336-9102
Mailing Address - Fax:770-674-8563
Practice Address - Street 1:2160 FOUNTAIN DR STE 220
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-7022
Practice Address - Country:US
Practice Address - Phone:678-336-9102
Practice Address - Fax:770-674-8563
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR096082363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000771196CMedicaid
GA50BBKVVOtherMEDICARE PROVIDER NUMBER
GA000771196CMedicaid