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General NPI Number Information
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NPI Number | 1356415244
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Entity Type | Organization
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Legal Business Name | GLOSTER NORTH FAMILY MEDICAL CLINIC INC
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Dates
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Enumeration Date | 11/20/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1714 N GLOSTER ST
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City | TUPELO
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State | MS
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Zip | 38804-1216
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Country | US
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Telephone | 662-841-5086
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Fax | 662-841-5088
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Provider Business Mailing Address
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Address Line | 1714 N GLOSTER ST
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City | TUPELO
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State | MS
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Zip | 38804-1216
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Country | US
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Telephone | 662-841-5086
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Fax | 662-841-5088
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Authorized Official
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Title or Position | OWNER
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Name | MS. MARY ANNE MASON
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Credential | APRN, BC
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Telephone | 662-841-5086
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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 | R866369
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License Number State | MS
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