Provider Demographics
NPI:1659871424
Name:ELLIS, AMANDA LEIGH (DNP, NP-C)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:LEIGH
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DNP, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-3617
Mailing Address - Country:US
Mailing Address - Phone:662-289-2880
Mailing Address - Fax:
Practice Address - Street 1:405 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3617
Practice Address - Country:US
Practice Address - Phone:662-289-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-17
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902514363LA2200X, 363LG0600X, 363LW0102X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health