Healthcare Provider Details

I. General information

NPI: 1497586366
Provider Name (Legal Business Name): PEYTON LOVELACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 08/12/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1827 SIMPSON HIGHWAY 149 STE C
MENDENHALL MS
39114-3439
US

IV. Provider business mailing address

1827 SIMPSON HIGHWAY 149 STE C
MENDENHALL MS
39114-3439
US

V. Phone/Fax

Practice location:
  • Phone: 601-847-2424
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number906804
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: