Healthcare Provider Details

I. General information

NPI: 1396202396
Provider Name (Legal Business Name): ROXANE THERESA MONCURE AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2019
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 MISSION 66 STE B
VICKSBURG MS
39180-3762
US

IV. Provider business mailing address

919 RUTHERFORD DR
JACKSON MS
39206-2033
US

V. Phone/Fax

Practice location:
  • Phone: 601-456-2598
  • Fax: 855-830-3484
Mailing address:
  • Phone: 601-259-6426
  • Fax: 601-376-2570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAG01190040
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: