Basic Information
| Provider Information | |||||||||
| NPI: | 1871802686 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIEVENDORF | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | JEANETTE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 SEVEN SPRINGS WAY | ||||||||
| Address2: | SUITE - 425 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159207878 | ||||||||
| FaxNumber: | 6159208775 | ||||||||
| Practice Location | |||||||||
| Address1: | 1655 BERNARDIN AVENUE | ||||||||
| Address2: | SUITE - 350 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032537575 | ||||||||
| FaxNumber: | 8032537571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2010 | ||||||||
| LastUpdateDate: | 01/19/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4341SC | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.