=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083487334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHYCONNECT OF MISSISSIPPI PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2023
-----------------------------------------------------
Last Update Date | 10/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1880 LAKELAND DR STE E
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-4916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 769-447-3042
-----------------------------------------------------
Fax | 769-447-3048
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1880 LAKELAND DR STE E
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-4916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 769-447-3042
-----------------------------------------------------
Fax | 769-447-3048
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMIN
-----------------------------------------------------
Name | WENDY HUGHES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 769-447-3042
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------