Healthcare Provider Details

I. General information

NPI: 1457836637
Provider Name (Legal Business Name): LAKELAND PREMIER WOMEN'S CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2506 LAKELAND DR STE 600
FLOWOOD MS
39232-7640
US

IV. Provider business mailing address

2506 LAKELAND DR STE 600
FLOWOOD MS
39232-7640
US

V. Phone/Fax

Practice location:
  • Phone: 601-420-0141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: RHONDA SULLIVAN-FORD
Title or Position: MD/OWNER
Credential: MD
Phone: 601-420-0141