1497152458 NPI number — MRS. DONNA DEMETRAL SNOW CNP

Table of content: MRS. DONNA DEMETRAL SNOW CNP (NPI 1497152458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497152458 NPI number — MRS. DONNA DEMETRAL SNOW CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SNOW
Provider First Name:
DONNA
Provider Middle Name:
DEMETRAL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNP
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:
1497152458
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3972 BETHAL ROBERTS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39345-3109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-683-3969
Provider Business Mailing Address Fax Number:
601-683-4303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 NORTHSIDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39345-2361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-683-4300
Provider Business Practice Location Address Fax Number:
601-683-4303
Provider Enumeration Date:
11/19/2014

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: 363LP0808X , with the licence number:  R863971 , 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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