=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366080665
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE HEALTH EXPRESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2019
-----------------------------------------------------
Last Update Date | 12/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 WHITTINGTON DR
-----------------------------------------------------
City | INDIANOLA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38751-3434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-303-5043
-----------------------------------------------------
Fax | 662-445-2532
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 WHITTINGTON DR
-----------------------------------------------------
City | INDIANOLA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38751-3434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-303-5043
-----------------------------------------------------
Fax | 662-445-2532
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. KAJUANDRA CHANDLER
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 662-303-5043
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------