Provider Demographics
NPI:1053369355
Name:BOYANTON, AMANDA KITCHENS (NP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KITCHENS
Last Name:BOYANTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:971 LAKELAND DR STE 353
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4607
Mailing Address - Country:US
Mailing Address - Phone:601-949-6990
Mailing Address - Fax:
Practice Address - Street 1:971 LAKELAND DR STE 353
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-949-6990
Practice Address - Fax:601-949-6105
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR804323363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP02579Medicare UPIN