Healthcare Provider Details

I. General information

NPI: 1851814875
Provider Name (Legal Business Name): STACI LEA HUDSON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. STACI LEA LUSH

II. Dates (important events)

Enumeration Date: 07/21/2017
Last Update Date: 11/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 HWY 51 SOUTH
HERNANDO MS
38632
US

IV. Provider business mailing address

2705 HWY 51 SOUTH
HERNANDO MS
38632
US

V. Phone/Fax

Practice location:
  • Phone: 662-449-1971
  • Fax:
Mailing address:
  • Phone: 662-449-1971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number902167
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: