Provider Demographics
NPI:1295166163
Name:COWART, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:COWART
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:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:SC
Mailing Address - Zip Code:29697-0099
Mailing Address - Country:US
Mailing Address - Phone:864-847-7377
Mailing Address - Fax:
Practice Address - Street 1:107 MELVIN LN
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:SC
Practice Address - Zip Code:29697-9363
Practice Address - Country:US
Practice Address - Phone:864-847-7377
Practice Address - Fax:864-847-3502
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC48154163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1104973577Medicaid