Provider Demographics
NPI:1801848494
Name:AUTRY, MICKIE G (ACNP)
Entity Type:Individual
Prefix:
First Name:MICKIE
Middle Name:G
Last Name:AUTRY
Suffix:
Gender:F
Credentials:ACNP
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 3488
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3488
Mailing Address - Country:US
Mailing Address - Phone:601-326-6401
Mailing Address - Fax:601-326-6405
Practice Address - Street 1:830 S GLOSTER ST
Practice Address - Street 2:STE 2
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4934
Practice Address - Country:US
Practice Address - Phone:662-377-7100
Practice Address - Fax:662-377-5736
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR873990363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07420783Medicaid
P01112717OtherMEDICARE RAILROAD
P01112717OtherMEDICARE RAILROAD
MS5121500597Medicare PIN