Provider Demographics
NPI:1962451302
Name:COON, LLEWELLYN (CNFP)
Entity Type:Individual
Prefix:MRS
First Name:LLEWELLYN
Middle Name:
Last Name:COON
Suffix:
Gender:F
Credentials:CNFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-3827
Mailing Address - Country:US
Mailing Address - Phone:601-250-1122
Mailing Address - Fax:601-250-0290
Practice Address - Street 1:1015 DELAWARE AVE STE C
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3827
Practice Address - Country:US
Practice Address - Phone:601-250-1122
Practice Address - Fax:601-250-0290
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR852964363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP13228Medicare UPIN
MS1962451302Medicare NSC
MS302I506467Medicare PIN
MS500000853Medicare PIN