| NPI | 1124802178 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DONNA LUCKETT Member 662-403-7741 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family |
| Additional Taxonomies | 207Q00000X Family Medicine |
| 363LP2300X Nurse Practitioner, Primary Care | |
| Enumeration Date | 2023-08-22 |
| Last Update Date | 2024-12-11 |