Basic Information
| Provider Information | |||||||||
| NPI: | 1184946170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | CLARK | ||||||||
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| Credential: | CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23666 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004749 | ||||||||
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| Practice Location | |||||||||
| Address1: | 728 CLINTON PKWY STE B | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390565227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004800 | ||||||||
| FaxNumber: | 6012004805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2010 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R871440 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | P01198568 | 01 | MS | RAILROAD MEDICARE | OTHER | 08287001 | 05 | MS | MEDICAID |