MEDICARE: MRS. AMBER RENEE AYLESWORTH AGNP

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	363LG0600X	Gerontology Nurse Practitioner	2021036268.	MS

General Provider Information

NPI Number	:	1780358192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMBER RENEE AYLESWORTH AGNP

Provider Business Mailing Address
First Line	:	3654 HOOD DR
Second Line	:
City	:	PEARL
State	:	MS
Zip	:	39208-3805
Country	:	US
Telephone Number	:	662-571-8731
Fax Number	:

Provider Business Practice Location Address
First Line	:	3654 HOOD DR
Second Line	:
City	:	PEARL
State	:	MS
Zip	:	39208-3805
Country	:	US
Telephone Number	:	662-571-8731
Fax Number	:

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

Provider Enumeration Date	:	08/09/2021
Last Update Date	:	08/09/2021

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