Provider Demographics
NPI:1730568692
Name:CESARE, AMANDA MCKENZIE (CPNP, PC, PMHS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MCKENZIE
Last Name:CESARE
Suffix:
Gender:M
Credentials:CPNP, PC, PMHS
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:CESARE
Other - Last Name:WHIDDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP, PC, PMHS
Mailing Address - Street 1:PO BOX 566
Mailing Address - Street 2:
Mailing Address - City:SUMRALL
Mailing Address - State:MS
Mailing Address - Zip Code:39482-0566
Mailing Address - Country:US
Mailing Address - Phone:601-467-6513
Mailing Address - Fax:
Practice Address - Street 1:4881 HIGHWAY 589
Practice Address - Street 2:
Practice Address - City:SUMRALL
Practice Address - State:MS
Practice Address - Zip Code:39482-4453
Practice Address - Country:US
Practice Address - Phone:601-336-9099
Practice Address - Fax:601-550-6184
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR879886363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03574867Medicaid
MS415801YKFFMedicare PIN