=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962870253
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENA WADE ANTHONY FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2015
-----------------------------------------------------
Last Update Date | 09/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 457 E MADISON ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38851-2308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-567-5005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5338 MS HIGHWAY 9
-----------------------------------------------------
City | EUPORA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39744-8606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-983-8438
-----------------------------------------------------
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 | R882626
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------