Provider Demographics
NPI:1831632322
Name:WOLLER, AMANDA JEANNINE (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEANNINE
Last Name:WOLLER
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JEANNINE
Other - Last Name:THORNTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AGACNP-BC
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:19 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1533
Practice Address - Country:US
Practice Address - Phone:762-235-3960
Practice Address - Fax:706-233-8505
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN213887363L00000X
TXAP141716363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner