Provider Demographics
NPI:1780358192
Name:AYLESWORTH, AMBER RENEE (AGNP)
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:RENEE
Last Name:AYLESWORTH
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3654 HOOD DR
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-3805
Mailing Address - Country:US
Mailing Address - Phone:662-571-8731
Mailing Address - Fax:
Practice Address - Street 1:3654 HOOD DR
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-3805
Practice Address - Country:US
Practice Address - Phone:662-571-8731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2021036268.363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology