Provider Demographics
NPI:1912921958
Name:ALI, AMY KAYE (FNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:KAYE
Last Name:ALI
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:KAYE
Other - Last Name:TOWNSEND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:11564 STANTON CIR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-6156
Mailing Address - Country:US
Mailing Address - Phone:228-896-1016
Mailing Address - Fax:
Practice Address - Street 1:3661 SANGANI BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:D'IBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39503
Practice Address - Country:US
Practice Address - Phone:228-354-0022
Practice Address - Fax:228-354-0088
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR861297363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09937019Medicaid
MS$$$$$$$$$OtherMS BCBS
MS09937019Medicaid
$$$$$$$$$OtherTRICARE
P73052Medicare UPIN