Provider Demographics
NPI:1205461167
Name:NUNLEY, PORTIA ELAINE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:PORTIA
Middle Name:ELAINE
Last Name:NUNLEY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:PORTIA
Other - Middle Name:ELAINE
Other - Last Name:NUNLEY-THOMPSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DNP
Mailing Address - Street 1:PO BOX 103
Mailing Address - Street 2:
Mailing Address - City:LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:39092-0103
Mailing Address - Country:US
Mailing Address - Phone:601-527-0636
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-9113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904120363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health