Provider Demographics
NPI:1669445680
Name:COLEBURN, AMANDA (FNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:COLEBURN
Suffix:
Gender:F
Credentials:FNP
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 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-777-7132
Mailing Address - Fax:843-777-4487
Practice Address - Street 1:800 E CHEVES ST
Practice Address - Street 2:SUITE 370
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2650
Practice Address - Country:US
Practice Address - Phone:843-665-2191
Practice Address - Fax:843-679-0818
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN 826363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0055Medicaid
SCS53143Medicare UPIN