Healthcare Provider Details

I. General information

NPI: 1518168210
Provider Name (Legal Business Name): HEATHER HANCOCK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 NORTHRIDGE RD
BALDWYN MS
38824-1173
US

IV. Provider business mailing address

1031 NORTHRIDGE RD
BALDWYN MS
38824-1173
US

V. Phone/Fax

Practice location:
  • Phone: 662-365-9305
  • Fax: 662-365-9304
Mailing address:
  • Phone: 662-365-9305
  • Fax: 662-365-9304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR860271
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: