Healthcare Provider Details

I. General information

NPI: 1952476921
Provider Name (Legal Business Name): PLANTERSVILLE CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2464 MAIN ST.
PLANTERSVILLE MS
38862
US

IV. Provider business mailing address

PO BOX 219
PLANTERSVILLE MS
38862-0219
US

V. Phone/Fax

Practice location:
  • Phone: 662-842-4877
  • Fax:
Mailing address:
  • Phone: 662-842-4877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR713511
License Number StateMS

VIII. Authorized Official

Name: MRS. DEBRA W HILL
Title or Position: SECRETARY
Credential: CFNP
Phone: 662-842-4877