Provider Demographics
NPI:1609131358
Name:MACKEY, DAVID PHILLIP JR (FNP-BC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:PHILLIP
Last Name:MACKEY
Suffix:JR
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5482 HIGHWAY 15 N
Mailing Address - Street 2:
Mailing Address - City:ECRU
Mailing Address - State:MS
Mailing Address - Zip Code:38841-8471
Mailing Address - Country:US
Mailing Address - Phone:662-488-8799
Mailing Address - Fax:662-488-8729
Practice Address - Street 1:845 S MADISON ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4905
Practice Address - Country:US
Practice Address - Phone:662-377-5930
Practice Address - Fax:662-377-5085
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR857999163WH0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03824819Medicaid