Healthcare Provider Details

I. General information

NPI: 1689769796
Provider Name (Legal Business Name): ADDIE PARKS HERROD CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1668 W PEACE ST
CANTON MS
39046-5332
US

IV. Provider business mailing address

PO BOX 588
CANTON MS
39046-0588
US

V. Phone/Fax

Practice location:
  • Phone: 601-859-5213
  • Fax: 601-859-8777
Mailing address:
  • Phone: 601-859-5213
  • Fax: 601-859-8771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR715247
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: