Healthcare Provider Details

I. General information

NPI: 1891050548
Provider Name (Legal Business Name): AMELIA S KUYKENDALL NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 GLOSTER CREEK VLG STE G1
TUPELO MS
38801-4751
US

IV. Provider business mailing address

4250 S EASON BLVD
TUPELO MS
38801-6549
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-2663
  • Fax:
Mailing address:
  • Phone: 662-377-5265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR864614
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number864614
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0812323
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number864614
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: