Healthcare Provider Details

I. General information

NPI: 1285519637
Provider Name (Legal Business Name): STACEY NICOLE ELKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2025
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 LAMAR ST
KILMICHAEL MS
39747-9002
US

IV. Provider business mailing address

1183 CUMBERLAND RD
MABEN MS
39750-6633
US

V. Phone/Fax

Practice location:
  • Phone: 662-262-5577
  • Fax:
Mailing address:
  • Phone: 662-418-7432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number907527
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: