Basic Information
| Provider Information | |||||||||
| NPI: | 1740926468 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARREN | ||||||||
| FirstName: | ANDREW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2144 LAKESHORE DR APT 4C | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391571028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2283271177 | ||||||||
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| Practice Location | |||||||||
| Address1: | 604 HWY 80 WEST, STE. R OFFICE 2 | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014732106 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2022 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.