Provider Demographics
NPI:1225667488
Name:CONWAY, RICKY BERNARD (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:BERNARD
Last Name:CONWAY
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5732 ANGLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206
Mailing Address - Country:US
Mailing Address - Phone:601-832-0616
Mailing Address - Fax:
Practice Address - Street 1:5732 ANGLE DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-3920
Practice Address - Country:US
Practice Address - Phone:601-832-0616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS860326163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical