Healthcare Provider Details

I. General information

NPI: 1659105955
Provider Name (Legal Business Name): EMERALD WELL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 LAMAR AVE STE 10
YAZOO CITY MS
39194-3242
US

IV. Provider business mailing address

3545 FOREST DR
GREENVILLE MS
38703-8202
US

V. Phone/Fax

Practice location:
  • Phone: 601-672-9730
  • Fax:
Mailing address:
  • Phone: 601-672-9730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CENTERIA GREEN WOOLFOLK
Title or Position: OWNER
Credential:
Phone: 601-672-9730