Provider Demographics
NPI:1710170899
Name:PANCHAME, AMANDA MARIE (NPC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIE
Last Name:PANCHAME
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 CANTON ROAD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060
Mailing Address - Country:US
Mailing Address - Phone:770-428-4486
Mailing Address - Fax:770-425-6005
Practice Address - Street 1:702 CANTON ROAD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-428-4486
Practice Address - Fax:770-425-6005
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN146197363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner