Provider Demographics
NPI:1801946876
Name:VARDAMAN, AMY CHRISTINE (NP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:CHRISTINE
Last Name:VARDAMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3788 IDLEWILD PL
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4619
Mailing Address - Country:US
Mailing Address - Phone:404-273-5225
Mailing Address - Fax:
Practice Address - Street 1:3788 IDLEWILD PL
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4619
Practice Address - Country:US
Practice Address - Phone:404-273-5225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN150639163WR0006X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52058526OtherBCBS ID #