Provider Demographics
NPI:1598217457
Name:RUBY, AMANDA JEAN (NP)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:JEAN
Last Name:RUBY
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:PO BOX 51827
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-0031
Mailing Address - Country:US
Mailing Address - Phone:843-353-2111
Mailing Address - Fax:
Practice Address - Street 1:3864 RENEE DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-4108
Practice Address - Country:US
Practice Address - Phone:843-353-2111
Practice Address - Fax:843-628-4326
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.18978-NP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health