Healthcare Provider Details

I. General information

NPI: 1255009114
Provider Name (Legal Business Name): JOHN BERNARD HARRIS IV AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2021
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CIRCLE J DR
LAUREL MS
39440-1980
US

IV. Provider business mailing address

30 CIRCLE J DR
LAUREL MS
39440-1980
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-0092
  • Fax:
Mailing address:
  • Phone: 601-425-0092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number906168
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number906168
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0000029981
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPN0000029981
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: