Provider Demographics
NPI:1447769559
Name:FAST PACE MISSISSIPPI, PLLC
Entity Type:Organization
Organization Name:FAST PACE MISSISSIPPI, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SYDNI
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-351-1791
Mailing Address - Street 1:6550 CAROTHERS PKWY STE 225
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6662
Mailing Address - Country:US
Mailing Address - Phone:931-253-1110
Mailing Address - Fax:931-253-1110
Practice Address - Street 1:517 CITY AVE S
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663
Practice Address - Country:US
Practice Address - Phone:662-587-8206
Practice Address - Fax:662-587-8207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-21
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07277821Medicaid