Healthcare Provider Details

I. General information

NPI: 1144382672
Provider Name (Legal Business Name): MARY T SMITH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 KATHERINE DR STE A
FLOWOOD MS
39232-9588
US

IV. Provider business mailing address

PO BOX 4128
MERIDIAN MS
39304-4128
US

V. Phone/Fax

Practice location:
  • Phone: 601-665-4162
  • Fax: 888-398-1151
Mailing address:
  • Phone: 601-581-7600
  • Fax: 601-483-5543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number668699
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: