Healthcare Provider Details

I. General information

NPI: 1790173599
Provider Name (Legal Business Name): RACHEL RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2014
Last Update Date: 09/08/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 JEFFERSON ST. SUITE 200
LAUREL MS
39440-4306
US

IV. Provider business mailing address

PO BOX 247
LAUREL MS
39441-0247
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-3520
  • Fax: 601-649-7899
Mailing address:
  • Phone: 601-425-7550
  • Fax: 601-399-6184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number866059
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR866059
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: