=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386057602
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA LEVENS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2014
-----------------------------------------------------
Last Update Date | 06/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9454 THREE RIVERS RD SUITE A
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39503-4294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-864-7747
-----------------------------------------------------
Fax | 228-864-7415
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9454 THREE RIVERS RD SUITE A
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39503-4294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-864-7747
-----------------------------------------------------
Fax | 228-864-7415
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | R863406
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------