Provider Demographics
NPI:1124532528
Name:LACK, AMANDA MAYS (APRN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MAYS
Last Name:LACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 HIGHWAY 28 BYP
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29624-3742
Mailing Address - Country:US
Mailing Address - Phone:864-772-8173
Mailing Address - Fax:833-996-1161
Practice Address - Street 1:108 HIGHWAY 28 BYP
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29624-3742
Practice Address - Country:US
Practice Address - Phone:864-772-8173
Practice Address - Fax:833-996-1161
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN162689363LA2200X
SC23238363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP6410Medicaid