Provider Demographics
NPI:1568914505
Name:CARTER-MCREYNOLDS, RITA (NP)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:CARTER-MCREYNOLDS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-5708
Mailing Address - Country:US
Mailing Address - Phone:601-693-0118
Mailing Address - Fax:601-965-0324
Practice Address - Street 1:14130 HIGHWAY 15 S STE D
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-6452
Practice Address - Country:US
Practice Address - Phone:662-779-1175
Practice Address - Fax:601-965-0324
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901737363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02978042Medicaid