Provider Demographics
NPI:1619274032
Name:DUBOSE, SUSAN L (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:DUBOSE
Suffix:
Gender:F
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-758-3100
Mailing Address - Fax:
Practice Address - Street 1:1238 HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:SUMRALL
Practice Address - State:MS
Practice Address - Zip Code:39482-9519
Practice Address - Country:US
Practice Address - Phone:601-758-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-21
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872039363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS12214870OtherC A Q H PROVIDER NUMBER
MS926646OtherAETNA
MS03388585Medicaid
MS302I509199Medicare PIN