Healthcare Provider Details

I. General information

NPI: 1386781151
Provider Name (Legal Business Name): MANDA SUE GRIFFIN DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 THIRD AVENUE HIGHWAY 32 WEST
HOULKA MS
38850-9004
US

IV. Provider business mailing address

400 THIRD AVENUE HIGHWAY 32 WEST
HOULKA MS
38850-9004
US

V. Phone/Fax

Practice location:
  • Phone: 662-568-2013
  • Fax: 662-568-2023
Mailing address:
  • Phone: 662-568-2013
  • Fax: 662-568-2023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR850148
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: