Healthcare Provider Details

I. General information

NPI: 1245910298
Provider Name (Legal Business Name): SAMANTHA GRACE BOREN PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 BRUNSON DR STE B
TUPELO MS
38801-4948
US

IV. Provider business mailing address

PO BOX 480
CORINTH MS
38835-0480
US

V. Phone/Fax

Practice location:
  • Phone: 662-432-1097
  • Fax: 833-707-1951
Mailing address:
  • Phone: 662-432-1097
  • Fax: 833-707-1951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberBORE-TLLM8M
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: