Provider Demographics
NPI:1104277474
Name:CLEGHORNE, AMANDA NICOLE (NP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:CLEGHORNE
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 1:4355 BROWNS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-4554
Mailing Address - Country:US
Mailing Address - Phone:770-771-5050
Mailing Address - Fax:770-771-5051
Practice Address - Street 1:4355 BROWNS BRIDGE RD STE 1
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-4554
Practice Address - Country:US
Practice Address - Phone:770-771-5050
Practice Address - Fax:770-771-5051
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN 218110363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN 218110OtherAPRN