Healthcare Provider Details

I. General information

NPI: 1457998965
Provider Name (Legal Business Name): KATIE MAE SPANN APRN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATIE MAE SPANN APRN PMHNP

II. Dates (important events)

Enumeration Date: 12/03/2019
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 HAWTHORNE PL
CLINTON MS
39056-3911
US

IV. Provider business mailing address

200 CAPITOL ST
CLINTON MS
39056-4026
US

V. Phone/Fax

Practice location:
  • Phone: 601-813-5680
  • Fax:
Mailing address:
  • Phone: 601-925-3205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number903657
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: