Healthcare Provider Details

I. General information

NPI: 1407506603
Provider Name (Legal Business Name): MATTHEW REESE PANNELL FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MATT PANNELL FNP-C

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 FAIRFIELD DR
NEW ALBANY MS
38652-3107
US

IV. Provider business mailing address

118 FAIRFIELD DR
NEW ALBANY MS
38652-3107
US

V. Phone/Fax

Practice location:
  • Phone: 662-534-0898
  • Fax: 662-534-8905
Mailing address:
  • Phone: 662-534-0898
  • Fax: 662-534-8905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number905281
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF03220787
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: