Healthcare Provider Details

I. General information

NPI: 1861255614
Provider Name (Legal Business Name): ADDISON PASSMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 KEY DR
MADISON MS
39110-7361
US

IV. Provider business mailing address

200 KEY DR
MADISON MS
39110-7361
US

V. Phone/Fax

Practice location:
  • Phone: 601-605-2085
  • Fax:
Mailing address:
  • Phone: 601-605-2085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number274416
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number907046
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: