Provider Demographics
NPI:1851172316
Name:MALONE, AMBER WATSON
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:WATSON
Last Name:MALONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6679 MS HIGHWAY 567
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MS
Mailing Address - Zip Code:39645-5285
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:178 MS HWY 24
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MS
Practice Address - Zip Code:39631-9049
Practice Address - Country:US
Practice Address - Phone:601-645-5361
Practice Address - Fax:601-645-5788
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906127363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily