Healthcare Provider Details

I. General information

NPI: 1063644599
Provider Name (Legal Business Name): AGNES PAMELA UPCHURCH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 SUNSET DR STE B
GRENADA MS
38901-4079
US

IV. Provider business mailing address

1350 SUNSET DR STE B
GRENADA MS
38901-4079
US

V. Phone/Fax

Practice location:
  • Phone: 662-229-0669
  • Fax: 662-227-9929
Mailing address:
  • Phone: 662-229-0669
  • Fax: 662-227-9929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR797137
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: