Healthcare Provider Details

I. General information

NPI: 1184166035
Provider Name (Legal Business Name): GRAYSON CREEK MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 10/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 JOHN EVERETT RD
MOSELLE MS
39459-9771
US

IV. Provider business mailing address

3 JOHN EVERETT RD
MOSELLE MS
39459-9771
US

V. Phone/Fax

Practice location:
  • Phone: 601-620-9991
  • Fax:
Mailing address:
  • Phone: 601-620-9991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number732001
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901749
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number732001
License Number StateMS

VIII. Authorized Official

Name: MACK E KNIGHT
Title or Position: OWNER
Credential: FNP-C
Phone: 601-408-9945