Healthcare Provider Details

I. General information

NPI: 1477017754
Provider Name (Legal Business Name): TERES CHANDLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 SCHOOL BUS DR
MABEN MS
39750-9408
US

IV. Provider business mailing address

43 SCHOOL BUS DR
MABEN MS
39750-9408
US

V. Phone/Fax

Practice location:
  • Phone: 662-295-7520
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number906219
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number904457
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: