Healthcare Provider Details

I. General information

NPI: 1841698792
Provider Name (Legal Business Name): AUDREY LEIGH UPCHURCH FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 LAKELAND DR
FLOWOOD MS
39232-9513
US

IV. Provider business mailing address

2510 LAKELAND DR
FLOWOOD MS
39232-9513
US

V. Phone/Fax

Practice location:
  • Phone: 601-355-1234
  • Fax: 601-718-2778
Mailing address:
  • Phone: 601-355-1234
  • Fax: 601-718-2778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR885008
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: