Healthcare Provider Details

I. General information

NPI: 1508236415
Provider Name (Legal Business Name): BETHANY SUMERFORD FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 E WOODROW WILSON AVE SUITE A-B
JACKSON MS
39216-4538
US

IV. Provider business mailing address

3502 W NORTHSIDE DR
JACKSON MS
39213-4454
US

V. Phone/Fax

Practice location:
  • Phone: 601-321-2234
  • Fax:
Mailing address:
  • Phone: 601-362-5321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR891236
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: