Provider Demographics
NPI:1609093665
Name:HIGGINBOTTOM, AMELIA MAE (NP)
Entity type:Individual
Prefix:MRS
First Name:AMELIA
Middle Name:MAE
Last Name:HIGGINBOTTOM
Suffix:
Gender:F
Credentials:NP
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 122
Mailing Address - Street 2:
Mailing Address - City:TREMONT
Mailing Address - State:MS
Mailing Address - Zip Code:38876-0122
Mailing Address - Country:US
Mailing Address - Phone:662-652-3361
Mailing Address - Fax:662-652-3363
Practice Address - Street 1:12725 HWY 23 N
Practice Address - Street 2:
Practice Address - City:TREMONT
Practice Address - State:MS
Practice Address - Zip Code:38876-0122
Practice Address - Country:US
Practice Address - Phone:662-652-3361
Practice Address - Fax:662-652-3363
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR560499363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116038Medicaid
MSS11332Medicare UPIN
MS500264717Medicare ID - Type Unspecified
MS00116038Medicaid