=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659128569
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA PRESLEY WHITE FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2024
-----------------------------------------------------
Last Update Date | 09/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 HWY 30 W
-----------------------------------------------------
City | NEW ALBANY
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38652-3112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 663-538-7631
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 270 COUNTY ROAD 1303
-----------------------------------------------------
City | GUNTOWN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38849-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-401-0865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WM0705X
-----------------------------------------------------
Taxonomy Name | Medical-Surgical Registered Nurse
-----------------------------------------------------
License Number | 875140
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 906982
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------