=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881388684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERESA S MONROE FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2023
-----------------------------------------------------
Last Update Date | 06/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6766 HWY 98W STE 1
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-550-3153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 KEYSTONE DR STE E
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39402-6124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-550-3153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 905874
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------