Provider Demographics
NPI:1588211916
Name:DORRIS, PATTYE (AGNP)
Entity Type:Individual
Prefix:
First Name:PATTYE
Middle Name:
Last Name:DORRIS
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 ROCKHILL RD
Mailing Address - Street 2:
Mailing Address - City:SARDIS
Mailing Address - State:MS
Mailing Address - Zip Code:38666-5070
Mailing Address - Country:US
Mailing Address - Phone:662-654-5110
Mailing Address - Fax:
Practice Address - Street 1:415 US HIGHWAY 49 N
Practice Address - Street 2:
Practice Address - City:TUTWILER
Practice Address - State:MS
Practice Address - Zip Code:38963-5091
Practice Address - Country:US
Practice Address - Phone:662-645-6567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902063363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS903062OtherNURSE PRACTIITONER LICENSE