Healthcare Provider Details

I. General information

NPI: 1669649570
Provider Name (Legal Business Name): HICKORY FLAT FAMILY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 OAK STREET
HICKOR FLAT MS
38633
US

IV. Provider business mailing address

PO BOX 128
HICKORY FLAT MS
38633-0128
US

V. Phone/Fax

Practice location:
  • Phone: 662-333-6378
  • Fax:
Mailing address:
  • Phone: 662-333-6387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberR687235
License Number StateMS

VIII. Authorized Official

Name: MS. DENISE WELLS GOSSETT
Title or Position: NURSE PRACTITIONER
Credential: CFNP
Phone: 662-202-5685