Provider Demographics
NPI:1679905574
Name:GAMMON, AMANDA (FNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GAMMON
Suffix:
Gender:F
Credentials:FNP
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 601643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1643
Mailing Address - Country:US
Mailing Address - Phone:704-355-0720
Mailing Address - Fax:704-355-5948
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:CMC ANNEX 1ST FLOOR
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-0720
Practice Address - Fax:704-355-5948
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC229546163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2540Medicaid
NC1679905574Medicaid
NCNCF124AMedicare PIN