Provider Demographics
NPI:1508409541
Name:POLHEMUS, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:POLHEMUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 OLD CHEROKEE ROAD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072
Mailing Address - Country:US
Mailing Address - Phone:803-520-9380
Mailing Address - Fax:803-520-5972
Practice Address - Street 1:198 RUTLEDGE AVENUE
Practice Address - Street 2:SUITE 1
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403
Practice Address - Country:US
Practice Address - Phone:843-723-0855
Practice Address - Fax:843-723-1307
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR240798363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics