1871674713 NPI number — SUSAN DUFFIE CFNP

Table of content: SUSAN DUFFIE CFNP (NPI 1871674713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871674713 NPI number — SUSAN DUFFIE CFNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUFFIE
Provider First Name:
SUSAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CFNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DUFFIE-MORGAN
Provider Other First Name:
SUSAN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CFNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871674713
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2434 S EASON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUPELO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38804-6942
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-844-1717
Provider Business Mailing Address Fax Number:
662-680-6416

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
499 GLOSTER CREEK VLG
Provider Second Line Business Practice Location Address:
SUITE A-3
Provider Business Practice Location Address City Name:
TUPELO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38801-4600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-844-1717
Provider Business Practice Location Address Fax Number:
662-680-6416
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R777236 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0123240 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com