Healthcare Provider Details

I. General information

NPI: 1477933745
Provider Name (Legal Business Name): GARRETT DOUGLAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

IV. Provider business mailing address

37 GOOD HOPE RD
COLUMBIA MS
39429-8914
US

V. Phone/Fax

Practice location:
  • Phone: 601-268-5650
  • Fax: 601-579-5212
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number882599
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number882599
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: