Provider Demographics
NPI:1104955632
Name:WHITLEY, AMANDA JOY (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:JOY
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1260
Mailing Address - Fax:704-384-1289
Practice Address - Street 1:13460 PLAZA ROAD EXT STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-8923
Practice Address - Country:US
Practice Address - Phone:704-316-4990
Practice Address - Fax:704-316-4998
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200900819207Q00000X
NC134118207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912958Medicaid
NCAC5385578R121OtherDEA
NCNC3186AMedicare PIN
NC2075111Medicare PIN