Basic Information
| Provider Information | |||||||||
| NPI: | 1457706434 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAGGETT | ||||||||
| FirstName: | AMANDA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 113 W JACKSON ST STE 2A | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391572402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016078222 | ||||||||
| FaxNumber: | 6019144804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2016 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 321999 | LA | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 01084596A | IN | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 30216 | MS | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.