Provider Demographics
NPI:1568091379
Name:AMAYA, SALLY GANTT (PA-C)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:GANTT
Last Name:AMAYA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:HALE
Other - Last Name:GANTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 7418
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORT
Mailing Address - State:AL
Mailing Address - Zip Code:36577-7418
Mailing Address - Country:US
Mailing Address - Phone:251-895-7133
Mailing Address - Fax:
Practice Address - Street 1:28490 2ND ST STE B
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-7150
Practice Address - Country:US
Practice Address - Phone:251-308-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA1550363A00000X
AL1550363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant