Provider Demographics
NPI:1508524802
Name:GREEN, AMANDA KNIGHTLY
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KNIGHTLY
Last Name:GREEN
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 1:25 SHADY OAK TRL
Mailing Address - Street 2:
Mailing Address - City:DEATSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36022-3612
Mailing Address - Country:US
Mailing Address - Phone:256-454-4374
Mailing Address - Fax:
Practice Address - Street 1:226 MITYLENE PARK DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3548
Practice Address - Country:US
Practice Address - Phone:334-875-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-128331208800000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208800000XAllopathic & Osteopathic PhysiciansUrology