Provider Demographics
NPI:1245785013
Name:BAHLER, AMANDA SULLIVAN (APRN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SULLIVAN
Last Name:BAHLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:PEGEEN
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:80 SEYMOUR STREET
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06102-5037
Mailing Address - Country:US
Mailing Address - Phone:860-545-5000
Mailing Address - Fax:
Practice Address - Street 1:105 CARNEGIE PL STE 103
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-5900
Practice Address - Country:US
Practice Address - Phone:770-716-7999
Practice Address - Fax:770-716-8444
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6612363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner