Provider Demographics
NPI:1629537634
Name:HEAD, AMANDA VALLEN (CPNP)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:VALLEN
Last Name:HEAD
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
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Mailing Address - Street 1:2041 BURNING BUSH LN
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-1120
Mailing Address - Country:US
Mailing Address - Phone:678-735-0524
Mailing Address - Fax:770-787-5050
Practice Address - Street 1:5211 HIGHWAY 278 NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2671
Practice Address - Country:US
Practice Address - Phone:770-787-7444
Practice Address - Fax:770-787-5050
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN102177208000000X
GARN181771363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN181771Medicaid