Healthcare Provider Details

I. General information

NPI: 1619703485
Provider Name (Legal Business Name): CLINT DYLAN GUNTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 S GLOSTER ST STE A
TUPELO MS
38801-6548
US

IV. Provider business mailing address

171 MAFFETT RD
PONTOTOC MS
38863-6935
US

V. Phone/Fax

Practice location:
  • Phone: 662-767-4200
  • Fax:
Mailing address:
  • Phone: 662-488-5330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number906882
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number906882
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: