Healthcare Provider Details

I. General information

NPI: 1699084020
Provider Name (Legal Business Name): AMANDA SMITH QUARLES CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 09/08/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NORTH STATE STREET DEPARTMENT OF MEDICINE DIVISION OF NEPHROLOGY
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 NORTH STATE STREET CBO-SUITE 4200
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5687
  • Fax: 601-984-5765
Mailing address:
  • Phone: 601-815-5047
  • Fax: 601-815-9596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR862128
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: