Basic Information
| Provider Information | |||||||||
| NPI: | 1376815134 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | O'HARA | ||||||||
| OtherFirstName: | GRACE | ||||||||
| OtherMiddleName: | P | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 305 W MOODY ST | ||||||||
| Address2: | |||||||||
| City: | POPLARVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394707338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017954543 | ||||||||
| FaxNumber: | 6017954238 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 HIGHWAY 11 S | ||||||||
| Address2: | |||||||||
| City: | POPLARVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394702625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014038283 | ||||||||
| FaxNumber: | 6014038283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2012 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 875721 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 12346339 | 01 | MS | CAQH | OTHER | 9858831 | 01 | MS | AETNA | OTHER | 07509343 | 05 | MS | MEDICAID |