Provider Demographics
NPI:1083964092
Name:HUBBARD, MARIEL (CPNP)
Entity Type:Individual
Prefix:
First Name:MARIEL
Middle Name:
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-3000
Mailing Address - Fax:601-579-5463
Practice Address - Street 1:101 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-9042
Practice Address - Country:US
Practice Address - Phone:601-579-3000
Practice Address - Fax:601-584-4727
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR880070363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08706760Medicaid
LA2406361Medicaid
MS256080YJ5DMedicare PIN