Basic Information
| Provider Information | |||||||||
| NPI: | 1861623027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRITT | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILBOURN | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-BC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 101 RICKY D BRITT SR BLVD # 2 | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386559103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622365442 | ||||||||
| FaxNumber: | 6622365295 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 RICKY D BRITT SR BLVD # 2 | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386559103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622365442 | ||||||||
| FaxNumber: | 6622365295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R867404 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 03956051 | 05 | MS | MEDICAID |