Provider Demographics
NPI:1821092479
Name:BERTHOLD, ANNE P (FNP)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:P
Last Name:BERTHOLD
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 1:1227 N STATE ST
Mailing Address - Street 2:STE 101
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2002
Mailing Address - Country:US
Mailing Address - Phone:601-355-2485
Mailing Address - Fax:601-353-1463
Practice Address - Street 1:1227 N STATE ST
Practice Address - Street 2:STE 101
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2002
Practice Address - Country:US
Practice Address - Phone:601-355-2485
Practice Address - Fax:601-353-1463
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR845073363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121962Medicaid
LA1432652Medicaid
LA1432652Medicaid
500012130Medicare PIN
MS00121962Medicaid