Provider Demographics
NPI:1376752832
Name:EARNEST, DALLAS MAXWELL (FNP)
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:MAXWELL
Last Name:EARNEST
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:DALLAS
Other - Middle Name:MAXWELL
Other - Last Name:RODGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1015 LEE DR STE 13
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-3619
Mailing Address - Country:US
Mailing Address - Phone:662-592-4170
Mailing Address - Fax:662-269-0226
Practice Address - Street 1:1015 LEE DR STE 13
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-3619
Practice Address - Country:US
Practice Address - Phone:662-592-4170
Practice Address - Fax:662-269-0226
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12310363LF0000X
MSR868182363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09128041Medicaid
MS09128041Medicaid
MS09128041Medicaid