Provider Demographics
NPI:1750858056
Name:BENNETT, AMANDA (CPNP)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 RIVERSIDE PKWY STE 207
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5926
Mailing Address - Country:US
Mailing Address - Phone:678-646-0404
Mailing Address - Fax:678-646-0202
Practice Address - Street 1:2000 RIVERSIDE PKWY STE 207
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5926
Practice Address - Country:US
Practice Address - Phone:678-646-0404
Practice Address - Fax:678-646-0202
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN216022363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics