Healthcare Provider Details

I. General information

NPI: 1174333413
Provider Name (Legal Business Name): HUNTER CHASE FAIRLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2025
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S GLOSTER ST
TUPELO MS
38801-4996
US

IV. Provider business mailing address

178A STEVE WILLIAMS RD
LUCEDALE MS
39452-5025
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number924749
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: