Basic Information
| Provider Information | |||||||||
| NPI: | 1144620287 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | MEAGAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | AGACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1080 RIVER OAKS DR STE B103 | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392327602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013661011 | ||||||||
| FaxNumber: | 6019326111 | ||||||||
| Practice Location | |||||||||
| Address1: | 1080 RIVER OAKS DR STE B103 | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392327602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013661011 | ||||||||
| FaxNumber: | 0193266111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2014 | ||||||||
| LastUpdateDate: | 05/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | R879439 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 09609876 | 05 | MS | MEDICAID |