Healthcare Provider Details

I. General information

NPI: 1962151308
Provider Name (Legal Business Name): AMBER NICOLE OVERSTREET AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 S FRONTAGE RD STE 107
VICKSBURG MS
39180-5882
US

IV. Provider business mailing address

PO BOX 1089
HAMMOND LA
70404-1089
US

V. Phone/Fax

Practice location:
  • Phone: 601-654-7070
  • Fax: 601-636-6233
Mailing address:
  • Phone: 985-892-7070
  • Fax: 985-892-7017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number905255
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: