Provider Demographics
NPI:1063651925
Name:MERRIETT, WARREN LANE JR
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:LANE
Last Name:MERRIETT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 NORTHGATE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-9162
Mailing Address - Country:US
Mailing Address - Phone:601-442-7141
Mailing Address - Fax:601-442-7343
Practice Address - Street 1:105 NORTHGATE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-9162
Practice Address - Country:US
Practice Address - Phone:601-442-7141
Practice Address - Fax:601-442-7343
Is Sole Proprietor?:No
Enumeration Date:2009-02-16
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860406363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily