Provider Demographics
NPI:1508506320
Name:BAGWELL, AMANDA NELSON (FNP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:NELSON
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1674 RANCHLAND RD
Mailing Address - Street 2:
Mailing Address - City:BELDEN
Mailing Address - State:MS
Mailing Address - Zip Code:38826-9634
Mailing Address - Country:US
Mailing Address - Phone:662-816-2391
Mailing Address - Fax:
Practice Address - Street 1:2215 JEFFERSON DAVIS DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5221
Practice Address - Country:US
Practice Address - Phone:662-638-0462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905143363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily