Provider Demographics
NPI:1023196821
Name:MCMAHAN, ELIZABETH (FNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MCMAHAN
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 1:2701 DAVIS STREET
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-5708
Mailing Address - Country:US
Mailing Address - Phone:601-693-0118
Mailing Address - Fax:601-553-8175
Practice Address - Street 1:927 KEMPER STREET
Practice Address - Street 2:
Practice Address - City:SCOOBA
Practice Address - State:MS
Practice Address - Zip Code:39358
Practice Address - Country:US
Practice Address - Phone:662-476-9595
Practice Address - Fax:601-553-8175
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR559237363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116995Medicaid
MS500000836Medicare Oscar/Certification
S47999Medicare UPIN