Healthcare Provider Details

I. General information

NPI: 1205592623
Provider Name (Legal Business Name): MARILYN SMITH PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 DR MARTIN LUTHER KING DR
DURANT MS
39063-3577
US

IV. Provider business mailing address

25 DR MARTIN LUTHER KING DR
DURANT MS
39063-3577
US

V. Phone/Fax

Practice location:
  • Phone: 662-739-9016
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number904801
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number904801
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: