1417424060 NPI number — MRS. LAURA WOOTTEN HODGES MPH, RD, LDN

Table of content: MRS. LAURA WOOTTEN HODGES MPH, RD, LDN (NPI 1417424060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417424060 NPI number — MRS. LAURA WOOTTEN HODGES MPH, RD, LDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HODGES
Provider First Name:
LAURA
Provider Middle Name:
WOOTTEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPH, RD, LDN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUSH
Provider Other First Name:
LAURA
Provider Other Middle Name:
WOOTTEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPH, RD, LDN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417424060
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5450 TRICK TALBERT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAILEY
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39320-9735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-527-7646
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 15TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39301-4138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-553-6284
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2018

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: 133N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , with the licence number: D1714 , 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)





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