Provider Demographics
NPI:1225123086
Name:MASSEY, THERESA M (FNP)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:M
Last Name:MASSEY
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 1:1413 W QUITMAN ST
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-1130
Mailing Address - Country:US
Mailing Address - Phone:662-424-9550
Mailing Address - Fax:662-424-9558
Practice Address - Street 1:1413 W QUITMAN ST
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1130
Practice Address - Country:US
Practice Address - Phone:662-424-9550
Practice Address - Fax:662-424-9558
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR530581363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0125347Medicaid
MS0125347Medicaid