Provider Demographics
NPI:1619693199
Name:DURRELL, MIA BEN'NA
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:BEN'NA
Last Name:DURRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 142
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069-0142
Mailing Address - Country:US
Mailing Address - Phone:601-597-9960
Mailing Address - Fax:
Practice Address - Street 1:100 FOXGATE AVE APT 31D
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1840
Practice Address - Country:US
Practice Address - Phone:601-597-9960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSNLM131887957001OtherBLUE CROSS BLUE SHIELD