Healthcare Provider Details

I. General information

NPI: 1093201980
Provider Name (Legal Business Name): MOLLY GRUBBS MAYHUGH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MOLLY MAYHUGH MOLLY GRUBBS

II. Dates (important events)

Enumeration Date: 07/03/2018
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 MAIN ST STE D
MONTICELLO MS
39654-3702
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-587-4304
  • Fax: 601-587-4515
Mailing address:
  • Phone: 601-200-4749
  • Fax: 601-200-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902712
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: