Provider Demographics
NPI:1598482135
Name:HERZOG, AMY (MSN, MPH, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:HERZOG
Suffix:
Gender:F
Credentials:MSN, MPH, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4384 HIGHWAY 382 W
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-6978
Mailing Address - Country:US
Mailing Address - Phone:706-255-9565
Mailing Address - Fax:706-995-6861
Practice Address - Street 1:4384 HIGHWAY 382 W
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-6978
Practice Address - Country:US
Practice Address - Phone:706-255-9565
Practice Address - Fax:706-995-6861
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN292472163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse