Healthcare Provider Details

I. General information

NPI: 1700885217
Provider Name (Legal Business Name): MARY BURNETT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 HIGHWAY 51 N
BATESVILLE MS
38606-2311
US

IV. Provider business mailing address

510 HIGHWAY 322 P O BOX 1216
CLARKSDALE MS
38614-4717
US

V. Phone/Fax

Practice location:
  • Phone: 662-563-1858
  • Fax: 662-563-0617
Mailing address:
  • Phone: 662-624-4292
  • Fax: 662-624-4354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR856909
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: