Provider Demographics
NPI:1649380940
Name:WINDHAM, BILLY R (FNP)
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:R
Last Name:WINDHAM
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 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:601-268-5630
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:103 TATUM PARK
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401
Practice Address - Country:US
Practice Address - Phone:601-268-5630
Practice Address - Fax:601-268-5819
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR810054363L00000X
MS810054363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS640507572KXOtherAMERICAN ADMIN GROUP
MS00114640Medicaid
MS640507572KXOtherAMERICAN ADMIN GROUP
R83898Medicare UPIN
MS500002174OtherRAIL ROAD MEDICARE