Healthcare Provider Details

I. General information

NPI: 1225932569
Provider Name (Legal Business Name): CHACIE MARIE FUNDERBURK BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 N GLOSTER ST
TUPELO MS
38804-3626
US

IV. Provider business mailing address

1551 COUNTY ROAD 641
BALDWYN MS
38824-9093
US

V. Phone/Fax

Practice location:
  • Phone: 662-542-3444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number915708
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: