Provider Demographics
NPI:1194503722
Name:BOULOS, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BOULOS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 JANMAR RD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-5606
Mailing Address - Country:US
Mailing Address - Phone:470-579-5600
Mailing Address - Fax:
Practice Address - Street 1:1371 CHURCH STREET EXT NE
Practice Address - Street 2:SUITE 200
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7913
Practice Address - Country:US
Practice Address - Phone:678-481-0579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-15
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12976363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical