Healthcare Provider Details

I. General information

NPI: 1538546247
Provider Name (Legal Business Name): MISSISSIPPI LACTATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 05/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 KATHERINE DR STE B
FLOWOOD MS
39232-9781
US

IV. Provider business mailing address

PO BOX 321412
FLOWOOD MS
39232-1412
US

V. Phone/Fax

Practice location:
  • Phone: 601-932-6455
  • Fax:
Mailing address:
  • Phone: 601-932-6455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9307
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. MICHAEL AUSTIN PUCKETT
Title or Position: CO-FOUNDER
Credential:
Phone: 601-932-6455