Provider Demographics
NPI:1891077137
Name:FAMILY CLINIC OF FALKNER, INC.
Entity Type:Organization
Organization Name:FAMILY CLINIC OF FALKNER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:QUINN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:662-512-0139
Mailing Address - Street 1:P O BOX 131
Mailing Address - Street 2:
Mailing Address - City:FALKNER
Mailing Address - State:MS
Mailing Address - Zip Code:38629-0131
Mailing Address - Country:US
Mailing Address - Phone:662-512-0139
Mailing Address - Fax:662-512-0438
Practice Address - Street 1:10150 CR 200
Practice Address - Street 2:
Practice Address - City:FALKNER
Practice Address - State:MS
Practice Address - Zip Code:38629-0131
Practice Address - Country:US
Practice Address - Phone:662-512-0139
Practice Address - Fax:662-512-0438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR764359363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03381311Medicaid