Basic Information
| Provider Information | |||||||||
| NPI: | 1285065292 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONERLY | ||||||||
| FirstName: | TERESA | ||||||||
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| Credential: | NPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 MCCRAY RD | ||||||||
| Address2: | |||||||||
| City: | JAYESS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396418053 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 430 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396547723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018257280 | ||||||||
| FaxNumber: | 6018258130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2013 | ||||||||
| LastUpdateDate: | 10/14/2016 | ||||||||
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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 | R855066 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.