Provider Demographics
NPI:1700042520
Name:COUCH, AMANDA BROOKE (NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BROOKE
Last Name:COUCH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:BROOKE
Other - Last Name:HUDGENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 1392
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29622-1392
Mailing Address - Country:US
Mailing Address - Phone:864-716-6050
Mailing Address - Fax:
Practice Address - Street 1:1922 MCCONNELL SPRINGS RD
Practice Address - Street 2:SUITE A
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2642
Practice Address - Country:US
Practice Address - Phone:864-716-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3656363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1517Medicaid
SCAA44497889Medicare PIN
SCNP1517Medicaid