Provider Demographics
NPI:1891269940
Name:MCARTHUR-MACISAAC, AMANDA LAINE (RN, BSN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LAINE
Last Name:MCARTHUR-MACISAAC
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-296-2780
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:5909 HIGHWAY 49 SOUTH,
Practice Address - Street 2:SUITE 30
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-296-2780
Practice Address - Fax:601-296-2781
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS880272163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator