Provider Demographics
NPI:1124419031
Name:HEAD, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:HEAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11240 HIGHWAY 49
Mailing Address - Street 2:STE 300
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4151
Mailing Address - Country:US
Mailing Address - Phone:228-284-4342
Mailing Address - Fax:228-284-4345
Practice Address - Street 1:11240 HIGHWAY 49
Practice Address - Street 2:STE 300
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4151
Practice Address - Country:US
Practice Address - Phone:228-284-4342
Practice Address - Fax:228-284-4345
Is Sole Proprietor?:No
Enumeration Date:2015-02-13
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR885800363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner