Healthcare Provider Details

I. General information

NPI: 1477594851
Provider Name (Legal Business Name): DANNY DEREK LANTRIP NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 E MADISON ST
HOUSTON MS
38851-2417
US

IV. Provider business mailing address

PO BOX 432
HOUSTON MS
38851-0432
US

V. Phone/Fax

Practice location:
  • Phone: 662-456-2800
  • Fax: 662-456-1715
Mailing address:
  • Phone: 662-456-2800
  • Fax: 662-456-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR853593
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: