Healthcare Provider Details

I. General information

NPI: 1134733728
Provider Name (Legal Business Name): COURTNEY S DUBOSE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 06/28/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 HIGHWAY 35 S
FOREST MS
39074-4000
US

IV. Provider business mailing address

1061 HIGHWAY 35 S
FOREST MS
39074-4000
US

V. Phone/Fax

Practice location:
  • Phone: 601-541-4313
  • Fax:
Mailing address:
  • Phone: 601-541-4313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number893316
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: