Healthcare Provider Details

I. General information

NPI: 1639634751
Provider Name (Legal Business Name): GRACE FAIRLEY HAMPTON MSN,APRN,FNP-C,CPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2019
Last Update Date: 12/09/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 N FLOWOOD DR
FLOWOOD MS
39232-9533
US

IV. Provider business mailing address

1031 N FLOWOOD DR
FLOWOOD MS
39232-9533
US

V. Phone/Fax

Practice location:
  • Phone: 601-487-7445
  • Fax: 601-487-7446
Mailing address:
  • Phone: 601-487-7445
  • Fax: 601-487-7446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902393
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: