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General NPI Number Information
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NPI Number | 1396379186
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Entity Type | Organization
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Legal Business Name | SOUTHERN FAMILY URGENT CARE LLC
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Dates
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Enumeration Date | 03/02/2020
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Last Update Date | 02/14/2023
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Provider Practice Location Address
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Address Line | 12303 HIGHWAY 49
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City | GULFPORT
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State | MS
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Zip | 39503-2780
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Country | US
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Telephone | 228-999-9999
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 787
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City | GRAND BAY
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State | AL
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Zip | 36541-0787
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Country | US
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Telephone | 228-206-6882
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Fax |
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Authorized Official
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Title or Position | OWNER/ NURSE PRACTITIONER
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Name | AMANDA R MIZELL
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Credential | FNP
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Telephone | 228-896-7108
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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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Taxonomy #2
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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