Provider Demographics
NPI:1679625115
Name:FAMILY NURSE CLINIC, INC
Entity Type:Organization
Organization Name:FAMILY NURSE CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:662-512-1685
Mailing Address - Street 1:1305 CITY AVE N
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38663-1157
Mailing Address - Country:US
Mailing Address - Phone:662-512-1685
Mailing Address - Fax:662-512-5403
Practice Address - Street 1:1305 CITY AVE N
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-1157
Practice Address - Country:US
Practice Address - Phone:662-512-1685
Practice Address - Fax:662-512-5403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04471830Medicaid
MS258971Medicare ID - Type Unspecified