Healthcare Provider Details

I. General information

NPI: 1154509628
Provider Name (Legal Business Name): JAMES W EMBRY NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4402 E ALOHA DR STE 16
DIAMONDHEAD MS
39525-3305
US

IV. Provider business mailing address

4402 E ALOHA DR STE 16
DIAMONDHEAD MS
39525-3305
US

V. Phone/Fax

Practice location:
  • Phone: 228-364-9001
  • Fax: 228-364-9004
Mailing address:
  • Phone: 228-364-9001
  • Fax: 228-364-9004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP05425
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR881886
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: