=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639654171
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHERINE ROSS FLYNN PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2018
-----------------------------------------------------
Last Update Date | 10/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 439 N JACKSON ST
-----------------------------------------------------
City | BROOKHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39601-2952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-835-9499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 427 HIGHWAY 51 N
-----------------------------------------------------
City | BROOKHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39601-2350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-833-6011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 902967
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------