Healthcare Provider Details

I. General information

NPI: 1225123086
Provider Name (Legal Business Name): THERESA M MASSEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 W QUITMAN ST
IUKA MS
38852-1130
US

IV. Provider business mailing address

1413 W QUITMAN ST
IUKA MS
38852-1130
US

V. Phone/Fax

Practice location:
  • Phone: 662-424-9550
  • Fax: 662-424-9558
Mailing address:
  • Phone: 662-424-9550
  • Fax: 662-424-9558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR530581
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: