Provider Demographics
NPI:1629186382
Name:PARKS, CARMEN (FNP)
Entity Type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:
Last Name:PARKS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 WILLOW PT STE 50
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1150
Mailing Address - Country:US
Mailing Address - Phone:601-296-3070
Mailing Address - Fax:601-296-3087
Practice Address - Street 1:207 ALCORN DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-8400
Practice Address - Country:US
Practice Address - Phone:662-287-3100
Practice Address - Fax:662-287-3435
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR723274363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSS76630Medicare UPIN