=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386840619
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA LEIGH WITT M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2007
-----------------------------------------------------
Last Update Date | 06/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 N STATE ST DEPARTMENT OF NEUROLOGY
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-984-2940
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 N STATE ST
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-984-5500
-----------------------------------------------------
Fax | 601-984-5503
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081N0008X
-----------------------------------------------------
Taxonomy Name | Neuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | A112554
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2081N0008X
-----------------------------------------------------
Taxonomy Name | Neuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | N7189
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2081N0008X
-----------------------------------------------------
Taxonomy Name | Neuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 21455
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------