Basic Information
Provider Information | |||||||||
NPI: | 1508815713 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALDRIDGE | ||||||||
FirstName: | MARCENIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | PROF. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNFP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 490 | ||||||||
Address2: |   | ||||||||
City: | MCCOMB | ||||||||
State: | MS | ||||||||
PostalCode: | 396490490 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6012504366 | ||||||||
FaxNumber: | 6012504367 | ||||||||
Practice Location | |||||||||
Address1: | 300 RAWLS DR STE 600 | ||||||||
Address2: |   | ||||||||
City: | MCCOMB | ||||||||
State: | MS | ||||||||
PostalCode: | 396482862 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6012494415 | ||||||||
FaxNumber: | 6012494474 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/08/2006 | ||||||||
LastUpdateDate: | 12/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R749464 | MS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 00125563 | 05 | MS |   | MEDICAID |