| NPI | 1043421357 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KELLEY DENISE MCCULLOUGH Office Manager 662-234-1090 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MS 13516) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MS 18438) |
| 207Q00000X Family Medicine (Licence: MS 10602) | |
| 363L00000X Nurse Practitioner (Licence: MS R728594) | |
| Enumeration Date | 2007-05-25 |
| Last Update Date | 2011-03-23 |