Healthcare Provider Details

I. General information

NPI: 1053280305
Provider Name (Legal Business Name): AQUARIUS TAYLOR-ROSS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2025
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E COMMERCE ST
HERNANDO MS
38632-2456
US

IV. Provider business mailing address

836 CLARINGTON DR
SOUTHAVEN MS
38671-6018
US

V. Phone/Fax

Practice location:
  • Phone: 662-298-2238
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number907816
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: