Provider Demographics
NPI:1497141337
Name:OMNIS SALUS, PLLC
Entity Type:Organization
Organization Name:OMNIS SALUS, PLLC
Other - Org Name:OMNIS HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FONDREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-251-7389
Mailing Address - Street 1:34 GLENWOOD DR.
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705
Mailing Address - Country:US
Mailing Address - Phone:662-570-1166
Mailing Address - Fax:662-570-1185
Practice Address - Street 1:7924 HIGHWAY 50 E
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39702-9592
Practice Address - Country:US
Practice Address - Phone:662-251-7389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR858548363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
388694ZL7YMedicare UPIN