1548450554 NPI number — MRS. AMANDA CANIZARO DEARMAN PT

Table of content: MRS. AMANDA CANIZARO DEARMAN PT (NPI 1548450554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548450554 NPI number — MRS. AMANDA CANIZARO DEARMAN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEARMAN
Provider First Name:
AMANDA
Provider Middle Name:
CANIZARO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEARMAN
Provider Other First Name:
MANDY
Provider Other Middle Name:
CANIZARO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1548450554
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
175 NUTMEG RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39046-2203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-672-8039
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 BURNEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-6621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-987-8200
Provider Business Practice Location Address Fax Number:
601-987-8211
Provider Enumeration Date:
07/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT3207 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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