Healthcare Provider Details

I. General information

NPI: 1245424688
Provider Name (Legal Business Name): LA-MISS PODIATRY & FOOT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2429 W COMMERCE ST STE A
OCEAN SPRINGS MS
39564-3124
US

IV. Provider business mailing address

2429 W COMMERCE ST STE A
OCEAN SPRINGS MS
39564-3124
US

V. Phone/Fax

Practice location:
  • Phone: 228-875-1141
  • Fax: 228-875-6885
Mailing address:
  • Phone: 228-875-1141
  • Fax: 228-875-6885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number80145
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number80145
License Number StateMS

VIII. Authorized Official

Name: DR. STEPHANIE F PHELAN
Title or Position: OWNER
Credential: DPM
Phone: 601-790-7710