Healthcare Provider Details

I. General information

NPI: 1912659608
Provider Name (Legal Business Name): GUADALUPE JISSELLE RODRIGUEZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2022
Last Update Date: 05/30/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 TURNER ST
MABEN MS
39750-9157
US

IV. Provider business mailing address

PO BOX 395
KOSCIUSKO MS
39090-0395
US

V. Phone/Fax

Practice location:
  • Phone: 662-263-5900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number904979
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: