Provider Demographics
NPI:1790485159
Name:DOWELL, AMANDA DIANNE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DIANNE
Last Name:DOWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:DIANE
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1089
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-1089
Mailing Address - Country:US
Mailing Address - Phone:985-892-7070
Mailing Address - Fax:985-892-7017
Practice Address - Street 1:2080 S FRONTAGE RD STE 107
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5882
Practice Address - Country:US
Practice Address - Phone:601-654-7070
Practice Address - Fax:601-636-6233
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905868363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily