Healthcare Provider Details

I. General information

NPI: 1023572294
Provider Name (Legal Business Name): COLBY PONDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W HAMILTON ST
HOUSTON MS
38851-2209
US

IV. Provider business mailing address

2434 S EASON BLVD
TUPELO MS
38804-6942
US

V. Phone/Fax

Practice location:
  • Phone: 662-598-8141
  • Fax: 662-796-3126
Mailing address:
  • Phone: 662-640-4595
  • Fax: 662-680-6416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number903137
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: