Provider Demographics
NPI:1174939219
Name:GREEN, AMANDA U (DNP,FNP-C)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:U
Last Name:GREEN
Suffix:
Gender:F
Credentials:DNP,FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1064 GARDNER RD STE 105
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5711
Mailing Address - Country:US
Mailing Address - Phone:854-429-1175
Mailing Address - Fax:
Practice Address - Street 1:1064 GARDNER RD STE 105-106
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5768
Practice Address - Country:US
Practice Address - Phone:854-429-1175
Practice Address - Fax:843-685-9467
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC217075163WM0705X
SC22248363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC2315A634OtherMEDICARE PTAN
SCNP5922Medicaid