Provider Demographics
NPI:1780575068
Name:PRINCE, AMANI
Entity type:Individual
Prefix:
First Name:AMANI
Middle Name:
Last Name:PRINCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-3963
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3963
Practice Address - Country:US
Practice Address - Phone:903-519-3954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX990283367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered