Provider Demographics
NPI:1851916837
Name:FOLSOM, AMANDA (PMHNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FOLSOM
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 STATELINE RD W
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-1610
Mailing Address - Country:US
Mailing Address - Phone:662-985-0625
Mailing Address - Fax:
Practice Address - Street 1:340 STATELINE RD W
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1610
Practice Address - Country:US
Practice Address - Phone:662-985-0625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-83076-121363LP0808X
MS903658363LP0808X
COC-APN.0004297-C-NP363LP0808X
TN30471363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health