Provider Demographics
NPI:1558972281
Name:KINCAID, PHALANECIA FONDRIEA (A2R7M5X9)
Entity Type:Individual
Prefix:MS
First Name:PHALANECIA
Middle Name:FONDRIEA
Last Name:KINCAID
Suffix:
Gender:F
Credentials:A2R7M5X9
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:MS
Mailing Address - Zip Code:39074-4137
Mailing Address - Country:US
Mailing Address - Phone:601-701-7753
Mailing Address - Fax:
Practice Address - Street 1:402 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-4137
Practice Address - Country:US
Practice Address - Phone:601-701-7753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA2R7M5X9291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory