Provider Demographics
NPI:1427588169
Name:CLOSE, AMANDA CARPENTER (APRN, CPNP-PC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CARPENTER
Last Name:CLOSE
Suffix:
Gender:F
Credentials:APRN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 GORDON CIR
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2644
Mailing Address - Country:US
Mailing Address - Phone:404-518-7817
Mailing Address - Fax:
Practice Address - Street 1:301 MEDICAL DR STE 504
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4172
Practice Address - Country:US
Practice Address - Phone:404-518-7817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN220550363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics