Provider Demographics
NPI:1336440312
Name:FORD, AMY LYNN
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:LYNN
Last Name:FORD
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 1:101 MANNING DR # 7160
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-4220
Mailing Address - Country:US
Mailing Address - Phone:984-974-3971
Mailing Address - Fax:984-974-3448
Practice Address - Street 1:101 MANNING DRIVE CB #7160
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27516
Practice Address - Country:US
Practice Address - Phone:984-974-3971
Practice Address - Fax:984-974-3448
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02567363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102985OtherMEDICAID