Provider Demographics
NPI:1013253103
Name:WHEELER, AMY MARIE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE
Last Name:WHEELER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 E COCHRAN RD SE
Mailing Address - Street 2:
Mailing Address - City:RANGER
Mailing Address - State:GA
Mailing Address - Zip Code:30734-6738
Mailing Address - Country:US
Mailing Address - Phone:770-894-1573
Mailing Address - Fax:
Practice Address - Street 1:104 PROMINENCE POINT PKWY
Practice Address - Street 2:SUITE 104
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-1236
Practice Address - Country:US
Practice Address - Phone:770-704-6988
Practice Address - Fax:770-720-8775
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN165493363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003130264A/B/CMedicaid
GA003130264A/B/CMedicaid