Healthcare Provider Details

I. General information

NPI: 1952282097
Provider Name (Legal Business Name): MITRA GHAFARIANPOOR APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 FOUNTAINS BLVD
MADISON MS
39110-6318
US

IV. Provider business mailing address

129 FOUNTAINS BLVD
MADISON MS
39110-6318
US

V. Phone/Fax

Practice location:
  • Phone: 769-300-0730
  • Fax: 601-949-2782
Mailing address:
  • Phone: 769-300-0730
  • Fax: 601-949-2782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number907773
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: