MEDICARE: MR. CHARLES W. CAPPS III 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	RN890049	MS

General Provider Information

NPI Number	:	1932576139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES W. CAPPS III FNP

Provider Business Mailing Address
First Line	:	515 S VICTORIA AVE
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732-3738
Country	:	US
Telephone Number	:	662-402-1447
Fax Number	:

Provider Business Practice Location Address
First Line	:	515 S VICTORIA AVE
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732-3738
Country	:	US
Telephone Number	:	662-402-1447
Fax Number	:

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

Provider Enumeration Date	:	08/24/2015
Last Update Date	:	08/24/2015

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