=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710635859
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YANNIQUE DANYELLE CRIGLAR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2022
-----------------------------------------------------
Last Update Date | 03/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 S LAMAR ST STE N400
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39201-4013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-604-3260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1521 N HILLS ST
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39305-1730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-604-3260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 324508
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------