Healthcare Provider Details

I. General information

NPI: 1386361871
Provider Name (Legal Business Name): MARY COPPOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2022
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 KATHERINE DRIVE SUITE A
FLOWOOD MS
39232-9588
US

IV. Provider business mailing address

200 LAKEVIEW DR
CLINTON MS
39056-4436
US

V. Phone/Fax

Practice location:
  • Phone: 601-665-4162
  • Fax: 855-830-3484
Mailing address:
  • Phone: 315-200-0197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number905500
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: