Healthcare Provider Details

I. General information

NPI: 1790876928
Provider Name (Legal Business Name): ANGIE S HARAWAY NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR SUITE 657
JACKSON MS
39216-4643
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-5955
  • Fax: 601-200-5957
Mailing address:
  • Phone: 601-200-4749
  • Fax: 601-200-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR862590
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: