Provider Demographics
NPI:1861451510
Name:FLETCHER, AUDWIN (CFNP)
Entity Type:Individual
Prefix:DR
First Name:AUDWIN
Middle Name:
Last Name:FLETCHER
Suffix:
Gender:M
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 WINDWARD DR
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39218-9589
Mailing Address - Country:US
Mailing Address - Phone:601-932-6010
Mailing Address - Fax:
Practice Address - Street 1:258 E FORTIFICATION ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2356
Practice Address - Country:US
Practice Address - Phone:601-815-8230
Practice Address - Fax:601-354-6289
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR791517363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119913Medicaid
MSS73632Medicare UPIN
MS500000441Medicare ID - Type Unspecified