Healthcare Provider Details

I. General information

NPI: 1619891306
Provider Name (Legal Business Name): ASHLI RICHARDSON VANDIVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 W QUITMAN ST
IUKA MS
38852-1132
US

IV. Provider business mailing address

585 POPLAR CIR
IUKA MS
38852-7415
US

V. Phone/Fax

Practice location:
  • Phone: 662-423-1000
  • Fax:
Mailing address:
  • Phone: 662-603-4123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number908674
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: