Healthcare Provider Details

I. General information

NPI: 1508702762
Provider Name (Legal Business Name): ANNACOLE POTTER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
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: 662-532-1544
Mailing address:
  • Phone: 662-532-1543
  • Fax: 662-532-1544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number908365
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number908365
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: