Provider Demographics
NPI:1720580376
Name:SHAFER, AMANDA L
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:SHAFER
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 1:3236 GREENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-3219
Mailing Address - Country:US
Mailing Address - Phone:404-857-9575
Mailing Address - Fax:888-857-4685
Practice Address - Street 1:3250 QUICK WATER LNDG NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4225
Practice Address - Country:US
Practice Address - Phone:404-857-9575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN225303363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily