Provider Demographics
NPI:1003898859
Name:MABRY, TINA U (FNP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:U
Last Name:MABRY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2065
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2065
Mailing Address - Country:US
Mailing Address - Phone:601-703-4282
Mailing Address - Fax:601-703-4597
Practice Address - Street 1:24489 HIGHWAY 80
Practice Address - Street 2:
Practice Address - City:LAKE
Practice Address - State:MS
Practice Address - Zip Code:39092-3511
Practice Address - Country:US
Practice Address - Phone:601-775-3264
Practice Address - Fax:601-775-3097
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR588199363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00013436Medicaid
500008623OtherRAILROAD MEDICARE
500008623OtherRAILROAD MEDICARE
500000004Medicare ID - Type Unspecified