Provider Demographics
NPI:1043326986
Name:FORREST, AMY M (CFNP)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:M
Last Name:FORREST
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 726
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38802
Mailing Address - Country:US
Mailing Address - Phone:662-678-1050
Mailing Address - Fax:662-678-1067
Practice Address - Street 1:149 N EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804
Practice Address - Country:US
Practice Address - Phone:662-678-1050
Practice Address - Fax:662-678-1067
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853933363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0121393Medicaid
500001564Medicare ID - Type Unspecified
MS0121393Medicaid
MSS92707Medicare UPIN