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General NPI Number Information
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NPI Number | 1093499907
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Entity Type | Organization
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Legal Business Name | MISSISSIPPI MEDICAL CLINIC OF MENDEHALL
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Dates
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Enumeration Date | 06/12/2023
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Last Update Date | 02/16/2024
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Provider Practice Location Address
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Address Line | 2170 SIMPSON HIGHWAY 49
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City | MENDENHALL
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State | MS
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Zip | 39114-5418
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Country | US
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Telephone | 601-675-1200
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Fax | 601-375-1209
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Provider Business Mailing Address
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Address Line | PO BOX 335
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City | MAGEE
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State | MS
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Zip | 39111-0335
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Country | US
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Telephone | 601-675-1200
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Fax | 601-675-1209
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Authorized Official
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Title or Position | OWNER
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Name | MRS. CHANTE N FERGUSON
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Credential | NP
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Telephone | 601-675-1200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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