Provider Demographics
NPI:1669806121
Name:AMAYA, MARTHA SANDRA
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:SANDRA
Last Name:AMAYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 JOHNSON LAKE RD SE
Mailing Address - Street 2:
Mailing Address - City:ADAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30103-3707
Mailing Address - Country:US
Mailing Address - Phone:706-844-2172
Mailing Address - Fax:
Practice Address - Street 1:108 OOTHCALOOGA ST
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-2332
Practice Address - Country:US
Practice Address - Phone:706-844-2172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-02
Last Update Date:2013-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT009079174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist