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General NPI Number Information
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NPI Number | 1659447878
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Entity Type | Organization
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Legal Business Name | CANTON FOOT CLINIC
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Dates
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Enumeration Date | 11/28/2006
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Last Update Date | 10/16/2008
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Provider Practice Location Address
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Address Line | 205 RIDGE PARK CV N
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City | RAYMOND
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State | MS
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Zip | 39154-9679
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Country | US
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Telephone | 601-672-7835
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Fax | 601-346-7133
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Provider Business Mailing Address
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Address Line | PO BOX 720894
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City | BYRAM
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State | MS
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Zip | 39272-0894
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Country | US
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Telephone | 601-672-7835
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Fax | 601-346-7133
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Authorized Official
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Title or Position | FNP
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Name | MRS. SANDRA F. THOMAS
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Credential | CNS
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Telephone | 601-672-7835
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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 | R772161
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License Number State | MS
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