Provider Demographics
NPI:1720562226
Name:MAHAN, AMANDA BRAND (FNP-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BRAND
Last Name:MAHAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 E MADISON ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851-2428
Mailing Address - Country:US
Mailing Address - Phone:662-456-1015
Mailing Address - Fax:662-456-1094
Practice Address - Street 1:1002 E MADISON ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-2428
Practice Address - Country:US
Practice Address - Phone:662-456-1015
Practice Address - Fax:662-456-1094
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902944363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner