Healthcare Provider Details

I. General information

NPI: 1073041042
Provider Name (Legal Business Name): JAN SHERLENE POLEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANICE SHERLENE PADEN FNP

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 06/27/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 EAST MADISON ST
HOUSTON MS
38851
US

IV. Provider business mailing address

4213 WALLFIELD RD
HOULKA MS
38850-9377
US

V. Phone/Fax

Practice location:
  • Phone: 662-456-4288
  • Fax:
Mailing address:
  • Phone: 662-419-0236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number902031
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: