Healthcare Provider Details

I. General information

NPI: 1578402020
Provider Name (Legal Business Name): RAELYNNE PUTMAN TERRY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2026
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S GLOSTER ST
TUPELO MS
38801-4934
US

IV. Provider business mailing address

189 COUNTY ROAD 14
HOULKA MS
38850-9638
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-2395
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number908342
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number888765
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: