Provider Demographics
NPI:1720273535
Name:NICOLS, AMANDA GRAY (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:GRAY
Last Name:NICOLS
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 1:501 MARSHALL STREET
Mailing Address - Street 2:SUITE 400
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1687
Mailing Address - Country:US
Mailing Address - Phone:601-354-0869
Mailing Address - Fax:
Practice Address - Street 1:501 MARSHALL STREET
Practice Address - Street 2:SUITE 400
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1687
Practice Address - Country:US
Practice Address - Phone:601-354-0869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20191207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08221030Medicaid
MS08221030Medicaid