Provider Demographics
NPI:1689769796
Name:HERROD, ADDIE PARKS (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:ADDIE
Middle Name:PARKS
Last Name:HERROD
Suffix:
Gender:F
Credentials:CFNP
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 588
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-0588
Mailing Address - Country:US
Mailing Address - Phone:601-859-5213
Mailing Address - Fax:601-859-8771
Practice Address - Street 1:1668 W PEACE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-5332
Practice Address - Country:US
Practice Address - Phone:601-859-5213
Practice Address - Fax:601-859-8777
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR715247363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08184344Medicaid
MS05179077Medicaid
MS$$$$$$$$$AOtherBLUE CROSS AND BLUE SHIELD OF MS
Q59434Medicare UPIN
MS05179077Medicaid
MS500002039Medicare ID - Type UnspecifiedINDIVIDUAL