Healthcare Provider Details

I. General information

NPI: 1609131358
Provider Name (Legal Business Name): DAVID PHILLIP MACKEY JR. FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 04/01/2020
Certification Date: 04/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 S MADISON ST
TUPELO MS
38801-4905
US

IV. Provider business mailing address

5482 HIGHWAY 15 N
ECRU MS
38841-8471
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-5930
  • Fax: 662-377-5085
Mailing address:
  • Phone: 662-488-8799
  • Fax: 662-488-8729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberR857999
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR857999
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: