Healthcare Provider Details

I. General information

NPI: 1962406959
Provider Name (Legal Business Name): SUSAN CASELLI CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 S FOURTH ST
ROLLING FORK MS
39159-5146
US

IV. Provider business mailing address

373 SAGO ROAD RT. 1 BOX 74N
ANGUILLA MS
38721
US

V. Phone/Fax

Practice location:
  • Phone: 662-873-0477
  • Fax: 662-873-0742
Mailing address:
  • Phone: 662-873-4666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR604569
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: