Healthcare Provider Details

I. General information

NPI: 1992324834
Provider Name (Legal Business Name): AMANDA ROSE SMITH FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 F E SELLERS HWY
MONTICELLO MS
39654-9378
US

IV. Provider business mailing address

PO BOX 490
MCCOMB MS
39649-0490
US

V. Phone/Fax

Practice location:
  • Phone: 601-587-7405
  • Fax:
Mailing address:
  • Phone: 601-249-2701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number903907
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: