Provider Demographics
NPI:1689002792
Name:PERCIVAL, AMANDA NICOLE HENRIE
Entity Type:Individual
Prefix:MRS
First Name:AMANDA NICOLE
Middle Name:HENRIE
Last Name:PERCIVAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 YOUNG POINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-3070
Mailing Address - Country:US
Mailing Address - Phone:334-312-5683
Mailing Address - Fax:
Practice Address - Street 1:2921 ZELDA RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2682
Practice Address - Country:US
Practice Address - Phone:334-277-5431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-131198363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily