Healthcare Provider Details

I. General information

NPI: 1003404732
Provider Name (Legal Business Name): KAYLA MARIE COOLEY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N FRONT ST
SANDERSVILLE MS
39477
US

IV. Provider business mailing address

1032 MORRISTON RD
PETAL MS
39465-9733
US

V. Phone/Fax

Practice location:
  • Phone: 601-490-7190
  • Fax: 601-490-7191
Mailing address:
  • Phone: 601-410-3924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number904346
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: