Basic Information
| Provider Information | |||||||||
| NPI: | 1184678716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BENNETT | ||||||||
| OtherFirstName: | MIRANDA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APN | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1211 S GLOSTER ST STE A | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388016548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627674200 | ||||||||
| FaxNumber: | 6627674204 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 BAPTIST MEMORIAL CIR STE 330 | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386554477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627674200 | ||||||||
| FaxNumber: | 6627674204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A810433 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.