Provider Demographics
NPI:1609538412
Name:TYLER, AMANDA ROSE (ACNPC-AG)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:TYLER
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 CARDINAL CIR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-3014
Mailing Address - Country:US
Mailing Address - Phone:843-615-3700
Mailing Address - Fax:
Practice Address - Street 1:1594 FREEDOM BLVD STE 100C
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6046
Practice Address - Country:US
Practice Address - Phone:843-674-4787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25169363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care