Healthcare Provider Details

I. General information

NPI: 1265961932
Provider Name (Legal Business Name): DONALD WELCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CIRCLE J DR STE 1
LAUREL MS
39440
US

IV. Provider business mailing address

30 CIRCLE J DR STE 1
LAUREL MS
39440-1981
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 TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number884785
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: