Healthcare Provider Details

I. General information

NPI: 1679114821
Provider Name (Legal Business Name): CYNTHIA SMITH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5681 HIGHWAY 363
MANTACHIE MS
38855-7632
US

IV. Provider business mailing address

115 DRIVE 1341
MOOREVILLE MS
38857-7426
US

V. Phone/Fax

Practice location:
  • Phone: 662-282-4226
  • Fax: 662-282-7946
Mailing address:
  • Phone: 662-523-5875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number903494
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: