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General NPI Number Information
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NPI Number | 1548047970
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Entity Type | Organization
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Legal Business Name | KUNTRY NURSE, LLC
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Dates
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Enumeration Date | 09/11/2023
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Last Update Date | 11/10/2024
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Provider Practice Location Address
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Address Line | 232 MARKET STREET SUITE 259
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City | FLOWOOD
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State | MS
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Zip | 39232-3339
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Country | US
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Telephone | 601-310-9784
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Fax |
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Provider Business Mailing Address
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Address Line | 1252 WEST GOVERNMENT STREET P.O. BOX 2336
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City | BRANDON
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State | MS
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Zip | 39043-2336
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Country | US
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Telephone | 601-310-9784
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | DAMETRA MANGUM
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Credential | FNP
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Telephone | 601-310-9784
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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