Provider Demographics
NPI:1508815713
Name:ALDRIDGE, MARCENIA (CNFP)
Entity Type:Individual
Prefix:PROF
First Name:MARCENIA
Middle Name:
Last Name:ALDRIDGE
Suffix:
Gender:F
Credentials:CNFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-0490
Mailing Address - Country:US
Mailing Address - Phone:601-250-4366
Mailing Address - Fax:601-250-4367
Practice Address - Street 1:300 RAWLS DR STE 600
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2862
Practice Address - Country:US
Practice Address - Phone:601-249-4415
Practice Address - Fax:601-249-4474
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR749464363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125563Medicaid
MS00125563Medicaid
MS500000952Medicare PIN