Healthcare Provider Details

I. General information

NPI: 1790485159
Provider Name (Legal Business Name): AMANDA DIANNE DOWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA DIANE PORTER

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
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 Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number905868
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: