MEDICARE: MARVELL SPEARS FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R703923	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548365901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARVELL SPEARS FNP

Provider Business Mailing Address
First Line	:	PO BOX 741
Second Line	:
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-0741
Country	:	US
Telephone Number	:	601-437-3050
Fax Number	:	601-437-3051

Provider Business Practice Location Address
First Line	:	2045 HIGHWAY 61 NORTH
Second Line	:
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-4262
Country	:	US
Telephone Number	:	601-437-3050
Fax Number	:	601-437-3051

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	01/13/2014

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