Healthcare Provider Details

I. General information

NPI: 1497478812
Provider Name (Legal Business Name): SAMANTHA JADE NEUHAUS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4381 S EASON BLVD STE 301
TUPELO MS
38801-6584
US

IV. Provider business mailing address

4381 S EASON BLVD STE 301
TUPELO MS
38801-6584
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-3008
  • Fax:
Mailing address:
  • Phone: 662-377-3008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number905575
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: