=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982140448
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A HEALTHY YOU MEDICAL CLINIC, 'L.L.C.'
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2017
-----------------------------------------------------
Last Update Date | 05/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1202 DESOTO AVE SUITE A
-----------------------------------------------------
City | CLARKSDALE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38614-6937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-209-1202
-----------------------------------------------------
Fax | 662-483-1627
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1202 DESOTO AVE SUITE A
-----------------------------------------------------
City | CLARKSDALE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38614-6937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-209-1202
-----------------------------------------------------
Fax | 662-483-1627
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | LULA OWENS HOSKINS
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 662-209-1202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------