Basic Information
| Provider Information | |||||||||
| NPI: | 1821092479 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERTHOLD | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | F.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1227 N STATE ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013552485 | ||||||||
| FaxNumber: | 6013531463 | ||||||||
| Practice Location | |||||||||
| Address1: | 1227 N STATE ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013552485 | ||||||||
| FaxNumber: | 6013531463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 12/02/2009 | ||||||||
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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 | R845073 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 00121962 | 05 | MS | MEDICAID | 1432652 | 05 | LA | MEDICAID |