Provider Demographics
NPI:1396017646
Name:FOUQUIER, MARY K (PHD, RN, CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:FOUQUIER
Suffix:
Gender:F
Credentials:PHD, RN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 N WEST ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2018
Mailing Address - Country:US
Mailing Address - Phone:601-354-6654
Mailing Address - Fax:601-354-6289
Practice Address - Street 1:1207 N WEST ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2018
Practice Address - Country:US
Practice Address - Phone:601-354-6654
Practice Address - Fax:601-354-6289
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25784367A00000X
MSR887487363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03285886Medicaid
MS358627YJ5DMedicare PIN