Provider Demographics
NPI:1003969304
Name:WARD, REBECCA PERRY (FNP)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:PERRY
Last Name:WARD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:214 DOGWOOD EST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-8273
Mailing Address - Country:US
Mailing Address - Phone:662-728-1154
Mailing Address - Fax:662-728-1154
Practice Address - Street 1:4381 SOUTH EASON BLVD
Practice Address - Street 2:LONGTOWN MEDICAL PARK
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801
Practice Address - Country:US
Practice Address - Phone:662-377-7354
Practice Address - Fax:662-377-5301
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR686093363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0114215Medicaid
MSS50488Medicare UPIN