Healthcare Provider Details

I. General information

NPI: 1003405754
Provider Name (Legal Business Name): CYNTHIA LYNN BEAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 JEFFERSON ST
LAUREL MS
39440-4354
US

IV. Provider business mailing address

PO BOX 247
LAUREL MS
39441-0247
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-2863
  • Fax:
Mailing address:
  • Phone: 601-425-7550
  • Fax: 601-399-6184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number904340
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: