Provider Demographics
NPI:1629427174
Name:GALLE, AMANDA J (NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:GALLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:DUNAWAY
Other - Last Name:RAYBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:6300 E LAKE BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6771
Mailing Address - Country:US
Mailing Address - Phone:228-230-2663
Mailing Address - Fax:228-546-3257
Practice Address - Street 1:6300 E LAKE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565
Practice Address - Country:US
Practice Address - Phone:228-230-2663
Practice Address - Fax:228-546-3257
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901566363L00000X
MSR884983163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS8655501Medicaid