Basic Information
| Provider Information | |||||||||
| NPI: | 1518336023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11170 SERENBE LN | ||||||||
| Address2: | |||||||||
| City: | CHATTAHOOCHEE HILLS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302682546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404049677 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1557 JANMAR RD | ||||||||
| Address2: | |||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300785686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783448900 | ||||||||
| FaxNumber: | 6786665201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2015 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MPA.2409 TL | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 8417 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.