1023196821 NPI number — ELIZABETH MCMAHAN FNP

Table of content: ELIZABETH MCMAHAN FNP (NPI 1023196821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023196821 NPI number — ELIZABETH MCMAHAN FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCMAHAN
Provider First Name:
ELIZABETH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023196821
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2701 DAVIS STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39301-5708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-693-0118
Provider Business Mailing Address Fax Number:
601-553-8175

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
927 KEMPER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOOBA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-476-9595
Provider Business Practice Location Address Fax Number:
601-553-8175
Provider Enumeration Date:
11/01/2006

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: 363L00000X , with the licence number:  R559237 , 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: 00116995 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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