Healthcare Provider Details

I. General information

NPI: 1720522535
Provider Name (Legal Business Name): MARION STACIE SAMMONS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
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: 601-425-0473
Mailing address:
  • Phone: 601-425-0092
  • Fax: 601-425-0473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901564
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: