MEDICARE: KINGS PSYCHIATRIC SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	R8396684	MS

General Provider Information

NPI Number	:	1023449329
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGS PSYCHIATRIC SERVICES LLC

Provider Business Mailing Address
First Line	:	713 FARMER ST
Second Line	:
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-2319
Country	:	US
Telephone Number	:	601-448-5176
Fax Number	:	601-448-5197

Provider Business Practice Location Address
First Line	:	713 FARMER ST
Second Line	:
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-2319
Country	:	US
Telephone Number	:	601-448-5176
Fax Number	:	601-448-5197

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. CHARLENE D KING
Credential	:	DNP, FPMHNP-BC
Telephone Number	:	601-448-5176

Provider Enumeration Date	:	12/12/2013
Last Update Date	:	03/01/2016

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