Healthcare Provider Details

I. General information

NPI: 1063768331
Provider Name (Legal Business Name): AMANDA STAUBLE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 N STATE ST
JACKSON MS
39202
US

IV. Provider business mailing address

104 WOODSTOCK DR
VICKSBURG MS
39180-5747
US

V. Phone/Fax

Practice location:
  • Phone: 601-201-7188
  • Fax:
Mailing address:
  • Phone: 601-201-7188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number903113
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: