Healthcare Provider Details

I. General information

NPI: 1326682998
Provider Name (Legal Business Name): KATHERINE ETHRIDGE SUMMERS CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 10/08/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 N OAK AVE
RULEVILLE MS
38771-3227
US

IV. Provider business mailing address

1110 DEERING ST
CLEVELAND MS
38732-3127
US

V. Phone/Fax

Practice location:
  • Phone: 662-756-4024
  • Fax:
Mailing address:
  • Phone: 205-382-0935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number904945
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: