Basic Information
| Provider Information | |||||||||
| NPI: | 1023067766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | BETTY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNFP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1007 W CONGRESS ST | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018339388 | ||||||||
| FaxNumber: | 6018339495 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 MARION AVE | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016846891 | ||||||||
| FaxNumber: | 6012493834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 08/12/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R135080 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 00119592 | 05 | MS | MEDICAID |