Healthcare Provider Details

I. General information

NPI: 1942318589
Provider Name (Legal Business Name): AMANDA S PENNY M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 04/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1867 CRANE RIDGE DR SUITE 101B
JACKSON MS
39216-4910
US

IV. Provider business mailing address

1867 CRANE RIDGE DR SUITE 101B
JACKSON MS
39216-4910
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-8776
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA92773
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20303
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: