Healthcare Provider Details

I. General information

NPI: 1083265284
Provider Name (Legal Business Name): KIDZ 1ST CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 E FIFTEENTH ST
YAZOO CITY MS
39194-2631
US

IV. Provider business mailing address

321 E FIFTEENTH ST
YAZOO CITY MS
39194-2631
US

V. Phone/Fax

Practice location:
  • Phone: 662-532-1543
  • Fax:
Mailing address:
  • Phone: 662-532-1543
  • Fax: 662-532-1544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY ALLISON BOWEN
Title or Position: OWNER
Credential: CPNP-PC
Phone: 662-532-1543