Provider Demographics
NPI:1396379186
Name:SOUTHERN FAMILY URGENT CARE LLC
Entity Type:Organization
Organization Name:SOUTHERN FAMILY URGENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MIZELL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:228-896-7108
Mailing Address - Street 1:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:GRAND BAY
Mailing Address - State:AL
Mailing Address - Zip Code:36541-0787
Mailing Address - Country:US
Mailing Address - Phone:228-206-6882
Mailing Address - Fax:
Practice Address - Street 1:12303 HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2780
Practice Address - Country:US
Practice Address - Phone:228-999-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-02
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03337280Medicaid