Healthcare Provider Details

I. General information

NPI: 1770824955
Provider Name (Legal Business Name): KIMBERLY M STANLEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2013
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 IVIE LN
MANTACHIE MS
38855-9764
US

IV. Provider business mailing address

280 FERGUSON LAKE RD
MARIETTA MS
38856-6068
US

V. Phone/Fax

Practice location:
  • Phone: 662-282-4197
  • Fax: 662-282-5121
Mailing address:
  • Phone: 662-401-3066
  • Fax: 662-842-4330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR858096
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: