Healthcare Provider Details

I. General information

NPI: 1396993663
Provider Name (Legal Business Name): AMY ADAMS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 JEFFERSON ST
LAUREL MS
39440-4243
US

IV. Provider business mailing address

PO BOX 247
LAUREL MS
39441-0247
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-4860
  • Fax: 601-426-4993
Mailing address:
  • Phone: 601-425-4860
  • Fax: 601-426-4993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number5094
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number21609
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: