Healthcare Provider Details

I. General information

NPI: 1891103313
Provider Name (Legal Business Name): CONNIE JEAN HODGE FNP-BC, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6399 GOODMAN RD STE 105
OLIVE BRANCH MS
38654-7063
US

IV. Provider business mailing address

6399 GOODMAN RD STE 105
OLIVE BRANCH MS
38654-7063
US

V. Phone/Fax

Practice location:
  • Phone: 662-300-6822
  • Fax:
Mailing address:
  • Phone: 662-300-6822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR858633
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR858633
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR858633
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: