Basic Information
| Provider Information | |||||||||
| NPI: | 1447769559 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAST PACE MISSISSIPPI, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6550 CAROTHERS PKWY STE 225 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370676662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312531110 | ||||||||
| FaxNumber: | 9312531110 | ||||||||
| Practice Location | |||||||||
| Address1: | 517 CITY AVE S | ||||||||
| Address2: | |||||||||
| City: | RIPLEY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6625878206 | ||||||||
| FaxNumber: | 6625878207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2017 | ||||||||
| LastUpdateDate: | 10/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | CLEMMONS | ||||||||
| AuthorizedOfficialFirstName: | SYDNI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9013511791 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 07277821 | 05 | MS | MEDICAID |