Healthcare Provider Details

I. General information

NPI: 1568610806
Provider Name (Legal Business Name): ANDREW C JUSTICE CFNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1495 MAPLE RD
NETTLETON MS
38858-6026
US

IV. Provider business mailing address

1495 MAPLE RD
NETTLETON MS
38858-6026
US

V. Phone/Fax

Practice location:
  • Phone: 662-963-9146
  • Fax: 662-963-9186
Mailing address:
  • Phone: 662-963-9146
  • Fax: 662-963-9186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR850606
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: