MEDICARE: JAMIE L CARPENTER FNP-C

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	163W00000X	Registered Nurse	163971	TN
2	363LF0000X	Family Nurse Practitioner	19660	TN
3	363L00000X	Nurse Practitioner	902936	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114318987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMIE L CARPENTER FNP-C

Provider Business Mailing Address
First Line	:	7145 GOODMAN RD
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-1904
Country	:	US
Telephone Number	:	662-333-5001
Fax Number	:	662-420-7063

Provider Business Practice Location Address
First Line	:	7145 GOODMAN RD
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-1904
Country	:	US
Telephone Number	:	662-333-5001
Fax Number	:	662-420-7063

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2015
Last Update Date	:	12/17/2018

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