Healthcare Provider Details

I. General information

NPI: 1942431200
Provider Name (Legal Business Name): AMANDA WYNNE ATWOOD CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2009
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 LAKELAND DR
JACKSON MS
39216-4644
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-3131
  • Fax: 601-200-3109
Mailing address:
  • Phone: 601-200-3131
  • Fax: 601-200-3109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR871950
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: