Provider Demographics
NPI:1538548029
Name:DIFFERENT, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:DIFFERENT
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 1:126 BENT CREEK DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6636
Mailing Address - Country:US
Mailing Address - Phone:601-672-8655
Mailing Address - Fax:
Practice Address - Street 1:578 LAKELAND EAST DR STE B
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9022
Practice Address - Country:US
Practice Address - Phone:601-932-0026
Practice Address - Fax:601-932-0027
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1228111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor