Basic Information
| Provider Information | |||||||||
| NPI: | 1992324834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 490 | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396490490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012492701 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1167 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396547682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015871433 | ||||||||
| FaxNumber: | 6015871625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2020 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 903907 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.