Healthcare Provider Details

I. General information

NPI: 1790491355
Provider Name (Legal Business Name): AGA DANEEN YOUNG WELLNESSPRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 N UTICA ST
TERRY MS
39170-8837
US

IV. Provider business mailing address

3072 LITTLE ROCK RD
CRYSTAL SPRINGS MS
39059-9558
US

V. Phone/Fax

Practice location:
  • Phone: 769-245-7938
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number3322-4030
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number3322-4030
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number3322-4030
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: