1023643715 NPI number — VANESSA LOUISE MCBRIDE NP-C

Table of content: VANESSA LOUISE MCBRIDE NP-C (NPI 1023643715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023643715 NPI number — VANESSA LOUISE MCBRIDE NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCBRIDE
Provider First Name:
VANESSA
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
VANESSA
Provider Other Middle Name:
LOUISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP-C
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1023643715
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
214 BARRINGTON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BYRAM
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39272-9239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-832-0974
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5160 GALAXIE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39206-4308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-713-0890
Provider Business Practice Location Address Fax Number:
601-366-3415
Provider Enumeration Date:
03/03/2020

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:  903727 , 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: 03138202 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1G0833 . This is a "PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 903727 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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