Provider Demographics
NPI:1467050419
Name:PARKER, VENTASHA S
Entity Type:Individual
Prefix:MRS
First Name:VENTASHA
Middle Name:S
Last Name:PARKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4635 HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-4226
Mailing Address - Country:US
Mailing Address - Phone:601-936-3833
Mailing Address - Fax:601-936-3837
Practice Address - Street 1:4635 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-4226
Practice Address - Country:US
Practice Address - Phone:601-936-3833
Practice Address - Fax:601-936-3837
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904217363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner