Provider Demographics
NPI:1619214541
Name:HANSON, AMANDA NICOLE (NP-C)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:NICOLE
Last Name:HANSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6510 HIGHWAY 90 STE A
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5015
Mailing Address - Country:US
Mailing Address - Phone:228-822-6148
Mailing Address - Fax:
Practice Address - Street 1:6510 HIGHWAY 90 STE A
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-5015
Practice Address - Country:US
Practice Address - Phone:228-822-6148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR875468363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS087588233Medicaid
MS385845YSCQOtherMEDICARE PTAN