Provider Demographics
NPI:1942431200
Name:ATWOOD, AMANDA WYNNE (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:WYNNE
Last Name:ATWOOD
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-3131
Mailing Address - Fax:601-200-3109
Practice Address - Street 1:890 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4644
Practice Address - Country:US
Practice Address - Phone:601-200-3131
Practice Address - Fax:601-200-3109
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR871950363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I501683OtherMEDICARE ST DOMINIC
MS05280758Medicaid
MSP01198583OtherRAILROAD MEDICARE