Provider Demographics
NPI:1699084020
Name:QUARLES, AMANDA SMITH (CFNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SMITH
Last Name:QUARLES
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:CBO-SUITE 4200
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-5047
Mailing Address - Fax:601-815-9596
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE DIVISION OF NEPHROLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5687
Practice Address - Fax:601-984-5765
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSR862128363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02632330Medicaid
MS302I502819Medicare PIN
MS302I508897Medicare PIN