Provider Demographics
NPI:1790491355
Name:YOUNG, AGA DANEEN (WELLNESSPRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:AGA
Middle Name:DANEEN
Last Name:YOUNG
Suffix:
Gender:F
Credentials:WELLNESSPRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3072 LITTLE ROCK RD
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-9558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:606 N UTICA ST
Practice Address - Street 2:
Practice Address - City:TERRY
Practice Address - State:MS
Practice Address - Zip Code:39170-8837
Practice Address - Country:US
Practice Address - Phone:769-245-7938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3322-40302083P0901X, 174H00000X, 171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS3322-4030Medicaid
2233-4030OtherNHA