Provider Demographics
NPI:1245537752
Name:PAGE, COREY AMANDA (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:COREY
Middle Name:AMANDA
Last Name:PAGE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:621 OLD HICKORY BOULEVARD
Mailing Address - Street 2:SUITE G
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305
Mailing Address - Country:US
Mailing Address - Phone:731-660-6402
Mailing Address - Fax:731-664-6603
Practice Address - Street 1:621 OLD HICKORY BLVD
Practice Address - Street 2:SUITE G
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2907
Practice Address - Country:US
Practice Address - Phone:731-660-6402
Practice Address - Fax:731-664-6603
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN160987163W00000X
TN15639363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN12249160OtherCAQH