Basic Information
| Provider Information | |||||||||
| NPI: | 1285693234 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMIDEI | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ACNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2198 WHITEHALL DR NE | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300667200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704246893 | ||||||||
| FaxNumber: | 6188190357 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704246893 | ||||||||
| FaxNumber: | 6788190357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 06/11/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | RN147435 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 784964376B(MARIETTA) | 05 | GA | MEDICAID | 784964376E-HIRAM | 05 | GA | MEDICAID | 784964376D(DOUGLAS) | 05 | GA | MEDICAID | 784964376C-WOODSTOCK | 05 | GA | MEDICAID | 784964376F(AUSTELL) | 05 | GA | MEDICAID |