Healthcare Provider Details

I. General information

NPI: 1265892749
Provider Name (Legal Business Name): PAMELA JEAN SANDERS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2016
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 SOUTHCREST CIR STE 212
SOUTHAVEN MS
38671-6721
US

IV. Provider business mailing address

PO BOX 1089
HAMMOND LA
70404-1089
US

V. Phone/Fax

Practice location:
  • Phone: 662-245-5270
  • Fax: 662-351-9471
Mailing address:
  • Phone: 615-425-4200
  • Fax: 615-425-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0000020782
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: