Provider Demographics
NPI:1851710685
Name:MCNULTY, AMANDA
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:MCNULTY
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 1:107 CYPRESS BND
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-5642
Mailing Address - Country:US
Mailing Address - Phone:904-557-4306
Mailing Address - Fax:912-576-5888
Practice Address - Street 1:308 BEDELL AVE
Practice Address - Street 2:
Practice Address - City:WOODBINE
Practice Address - State:GA
Practice Address - Zip Code:31569-2091
Practice Address - Country:US
Practice Address - Phone:912-576-5999
Practice Address - Fax:912-576-5888
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN218786363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily