=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073251658
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAITLYN ROUSSE WARREN DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2022
-----------------------------------------------------
Last Update Date | 07/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 WEEMS ST
-----------------------------------------------------
City | PURVIS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39475-4062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-794-2224
-----------------------------------------------------
Fax | 601-794-6392
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 558 OLD HIGHWAY 11
-----------------------------------------------------
City | LUMBERTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39455-7623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 32762
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------