Provider Demographics
NPI:1750458832
Name:PRIDGEN, AMY
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:
Last Name:PRIDGEN
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 1:1509 ATKINSON ROAD
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043
Mailing Address - Country:US
Mailing Address - Phone:770-995-2379
Mailing Address - Fax:770-995-2385
Practice Address - Street 1:1509 ATKINSON RD
Practice Address - Street 2:SUITE 1100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-7986
Practice Address - Country:US
Practice Address - Phone:770-995-2379
Practice Address - Fax:770-995-2385
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006506174400000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA306069Medicaid
GA000843554AMedicaid
GA0008436554AMedicaid
GA10037759Medicaid