Basic Information
| Provider Information | |||||||||
| NPI: | 1881000255 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMARADASA | ||||||||
| FirstName: | NATALI | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 547 | ||||||||
| Address2: | |||||||||
| City: | LITTLE RIVER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295660547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436638000 | ||||||||
| FaxNumber: | 8436638123 | ||||||||
| Practice Location | |||||||||
| Address1: | 4220 CAROLINA EXCHANGE DRIVE | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295794220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436638000 | ||||||||
| FaxNumber: | 8436638123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2014 | ||||||||
| LastUpdateDate: | 12/02/2019 | ||||||||
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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 | 18864 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | GP4505 | 05 | SC | MEDICAID | NP2919 | 05 | SC | MEDICAID |