Provider Demographics
NPI:1821712415
Name:MIMS, AMANDA (MSN, AGNP-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MIMS
Suffix:
Gender:F
Credentials:MSN, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 VALLEY VIEW LN STE 700
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-5045
Mailing Address - Country:US
Mailing Address - Phone:855-984-5121
Mailing Address - Fax:
Practice Address - Street 1:4055 VALLEY VIEW LN STE 700
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-5045
Practice Address - Country:US
Practice Address - Phone:855-984-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-155145363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner