Basic Information
| Provider Information | |||||||||
| NPI: | 1265788251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | MARLA | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SUTHERLAND | ||||||||
| OtherFirstName: | MARLA | ||||||||
| OtherMiddleName: | N. | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 445 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | MEADVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013843720 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 54 SERGEANT PRENTISS DR | ||||||||
| Address2: | |||||||||
| City: | NATCHEZ | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391204726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014332100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2012 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN080053-AP06630 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | R823883 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP06630 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 09332548 | 05 | MS | MEDICAID |