Healthcare Provider Details

I. General information

NPI: 1124781240
Provider Name (Legal Business Name): REBECCA ERIN MCKINNEY FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2021
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 S MADISON ST
TUPELO MS
38801-4905
US

IV. Provider business mailing address

830 S GLOSTER ST
TUPELO MS
38801-4934
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-3000
  • Fax:
Mailing address:
  • Phone: 662-377-3889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number904954
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: