Healthcare Provider Details

I. General information

NPI: 1902196652
Provider Name (Legal Business Name): KATIE ELISABETH RATTRAY CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NORTH STATE STREET DEPARTMENT OF MEDICINE, DIVISION OF CARDIOLOGY
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST CARDIOLOGY
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5678
  • Fax: 601-984-5638
Mailing address:
  • Phone: 601-984-5678
  • Fax: 601-984-5638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberAL 1-116844
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberR890561
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: