Healthcare Provider Details

I. General information

NPI: 1821343898
Provider Name (Legal Business Name): MARY WHEATLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 PARK PL
CLINTON MS
39056-6111
US

IV. Provider business mailing address

107 PARK PL
CLINTON MS
39056-6111
US

V. Phone/Fax

Practice location:
  • Phone: 601-260-7937
  • Fax:
Mailing address:
  • Phone: 601-260-7937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number04266
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: