Healthcare Provider Details

I. General information

NPI: 1588311732
Provider Name (Legal Business Name): SUSAN OLIVIA HODGES DNP, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2022
Last Update Date: 03/12/2022
Certification Date: 03/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 E MADISON ST
HOUSTON MS
38851-2428
US

IV. Provider business mailing address

1002 E MADISON ST
HOUSTON MS
38851-2428
US

V. Phone/Fax

Practice location:
  • Phone: 662-456-3700
  • Fax:
Mailing address:
  • Phone: 662-456-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number905214
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: