Healthcare Provider Details

I. General information

NPI: 1396362083
Provider Name (Legal Business Name): SARA WITHROW NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 OLD CANTON RD
JACKSON MS
39211-5982
US

IV. Provider business mailing address

4400 OLD CANTON RD
JACKSON MS
39211-5982
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5236
  • Fax:
Mailing address:
  • Phone: 601-984-5236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number903966
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: