MEDICARE: AMANDA LAINE MCARTHUR-MACISAAC RN, BSN

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	163WD0400X	Diabetes Educator Registered Nurse	880272	MS

General Provider Information

NPI Number	:	1891269940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA LAINE MCARTHUR-MACISAAC RN, BSN

Provider Business Mailing Address
First Line	:	415 S 28TH AVE
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39401-7246
Country	:	US
Telephone Number	:	601-296-2780
Fax Number	:	601-579-5240

Provider Business Practice Location Address
First Line	:	5909 HIGHWAY 49 SOUTH,
Second Line	:	SUITE 30
City	:	HATTIESBURG
State	:	MS
Zip	:	39402
Country	:	US
Telephone Number	:	601-296-2780
Fax Number	:	601-296-2781

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

Provider Enumeration Date	:	01/11/2019
Last Update Date	:	01/11/2019

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