Provider Demographics
NPI:1063463677
Name:MORGAN, SALLY LAWSON (NP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:LAWSON
Last Name:MORGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NETTLETON
Mailing Address - State:MS
Mailing Address - Zip Code:38858-6075
Mailing Address - Country:US
Mailing Address - Phone:662-963-5050
Mailing Address - Fax:662-963-5051
Practice Address - Street 1:182 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NETTLETON
Practice Address - State:MS
Practice Address - Zip Code:38858
Practice Address - Country:US
Practice Address - Phone:662-963-5050
Practice Address - Fax:662-963-5051
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR682446363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117719Medicaid
MS414002YZ8ZMedicare PIN
MSS30584Medicare UPIN