Basic Information
| Provider Information | |||||||||
| NPI: | 1346845096 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOLD | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 37 WIND TREE CV | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383052974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5709034683 | ||||||||
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| Practice Location | |||||||||
| Address1: | 270 E COURT AVE | ||||||||
| Address2: | |||||||||
| City: | SELMER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383752304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316457932 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2020 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 1697 | AL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 363A00000X | 1697 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 5112 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.