Provider Demographics
NPI:1750103974
Name:PARKER, AMANDA (CRT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PARKER
Suffix:
Gender:F
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 WILLOW PL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6389
Mailing Address - Country:US
Mailing Address - Phone:601-502-6054
Mailing Address - Fax:
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRCP-2132225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist