Provider Demographics
NPI:1912220237
Name:HAM, AMANDA LEE (ANP-BC, PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LEE
Last Name:HAM
Suffix:
Gender:F
Credentials:ANP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 GANN ST
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-1337
Mailing Address - Country:US
Mailing Address - Phone:662-279-0631
Mailing Address - Fax:662-293-4254
Practice Address - Street 1:611 ALCORN DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9321
Practice Address - Country:US
Practice Address - Phone:662-293-1160
Practice Address - Fax:662-293-4254
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS855720363LP0808X
MSR855720363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07200316Medicaid