Provider Demographics
NPI:1063768331
Name:STAUBLE, AMANDA (APRN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:STAUBLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 WOODSTOCK DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5747
Mailing Address - Country:US
Mailing Address - Phone:601-201-7188
Mailing Address - Fax:
Practice Address - Street 1:1225 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202
Practice Address - Country:US
Practice Address - Phone:601-201-7188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903113363LF0000X
MSR860063163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR860063OtherRN LICENSE
MS903113OtherFAMILY NURSE PRACTITIONER