Healthcare Provider Details

I. General information

NPI: 1295187789
Provider Name (Legal Business Name): THITIPORN SRIPRASERT WHALEY NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THITIPORN SRIPRASERT

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 02/06/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

346 STATELINE RD W
SOUTHAVEN MS
38671-1610
US

IV. Provider business mailing address

346 STATELINE RD W
SOUTHAVEN MS
38671-1610
US

V. Phone/Fax

Practice location:
  • Phone: 662-510-5353
  • Fax:
Mailing address:
  • Phone: 662-510-5353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901516
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: