Provider Demographics
NPI:1023897055
Name:KIERNAN, AMANDA LEANN (LICENSED OPTICIAN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEANN
Last Name:KIERNAN
Suffix:
Gender:F
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 COBB PKWY SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-7629
Mailing Address - Country:US
Mailing Address - Phone:770-250-7510
Mailing Address - Fax:770-953-4113
Practice Address - Street 1:2201 COBB PKWY SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-7629
Practice Address - Country:US
Practice Address - Phone:770-250-7510
Practice Address - Fax:770-953-4113
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2889156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty