MEDICARE: AMY O'DANIEL FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R857611	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669879003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY O'DANIEL FNP-C

Provider Business Mailing Address
First Line	:	3411 W MAIN ST
Second Line	:
City	:	TUPELO
State	:	MS
Zip	:	38801-9413
Country	:	US
Telephone Number	:	662-844-9376
Fax Number	:	662-844-4326

Provider Business Practice Location Address
First Line	:	3411 W MAIN ST
Second Line	:
City	:	TUPELO
State	:	MS
Zip	:	38801-9413
Country	:	US
Telephone Number	:	662-844-9376
Fax Number	:	662-844-4326

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2014
Last Update Date	:	05/26/2016

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