Provider Demographics
NPI:1124359229
Name:STATEN, RACHEL LORRAINE (PMHNP)
Entity Type:Individual
Prefix:MISS
First Name:RACHEL
Middle Name:LORRAINE
Last Name:STATEN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 GRAND OLE OAKS DR
Mailing Address - Street 2:APT # 2
Mailing Address - City:BELDEN
Mailing Address - State:MS
Mailing Address - Zip Code:38826-7014
Mailing Address - Country:US
Mailing Address - Phone:662-269-2105
Mailing Address - Fax:
Practice Address - Street 1:112 GRAND OLE OAKS DR
Practice Address - Street 2:APT # 2
Practice Address - City:BELDEN
Practice Address - State:MS
Practice Address - Zip Code:38826-7014
Practice Address - Country:US
Practice Address - Phone:662-269-2105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR883957363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08855320Medicaid