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General NPI Number Information
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NPI Number | 1023474780
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Entity Type | Organization
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Legal Business Name | WINSTON MEDICAL CLINIC FAIR ELEMENTARY SCHOOL
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Dates
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Enumeration Date | 01/12/2016
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Last Update Date | 01/12/2016
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Provider Practice Location Address
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Address Line | 301 N COLUMBUS AVE
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City | LOUISVILLE
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State | MS
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Zip | 39339-2315
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Country | US
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Telephone | 662-446-1972
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Fax | 662-446-1039
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Provider Business Mailing Address
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Address Line | PO BOX 470
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City | LOUISVILLE
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State | MS
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Zip | 39339-0470
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Country | US
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Telephone | 662-446-1972
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Fax | 552-446-1039
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Authorized Official
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Title or Position | DIRECTOR OF CLINIC OPERATIONS
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Name | DEBRA J FRYERY
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Credential |
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Telephone | 662-446-1972
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | R860217
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License Number State | MS
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