Healthcare Provider Details

I. General information

NPI: 1770184467
Provider Name (Legal Business Name): REBECCA LITTLE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2020
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 VETERANS MEMORIAL DR
KOSCIUSKO MS
39090-3424
US

IV. Provider business mailing address

156 E WALNUT AVE
EUPORA MS
39744-2027
US

V. Phone/Fax

Practice location:
  • Phone: 662-633-4216
  • Fax: 662-633-4217
Mailing address:
  • Phone: 662-258-8293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number903924
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: