Provider Demographics
NPI:1942318589
Name:PENNY, AMANDA S (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:PENNY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1867 CRANE RIDGE DR
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1867 CRANE RIDGE DR
Practice Address - Street 2:SUITE 101B
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4910
Practice Address - Country:US
Practice Address - Phone:601-362-8776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92773208000000X
MS20303208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics