Healthcare Provider Details

I. General information

NPI: 1730774290
Provider Name (Legal Business Name): FARELON ELISE RANDLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2021
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 RUSSELL ST STE 3
STARKVILLE MS
39759-5411
US

IV. Provider business mailing address

830 S GLOSTER ST
TUPELO MS
38801-4996
US

V. Phone/Fax

Practice location:
  • Phone: 662-324-2244
  • Fax:
Mailing address:
  • Phone: 662-377-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number905602
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: