Provider Demographics
NPI:1205932134
Name:PHELPS, BARBARA J
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:J
Last Name:PHELPS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BARBARA
Other - Middle Name:J
Other - Last Name:PHELPS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CFNP
Mailing Address - Street 1:3510 PEMBERTON SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5506
Mailing Address - Country:US
Mailing Address - Phone:601-501-6991
Mailing Address - Fax:
Practice Address - Street 1:3502 W NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-4454
Practice Address - Country:US
Practice Address - Phone:601-362-5321
Practice Address - Fax:601-364-2600
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR586773363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115977Medicaid
MS00115977Medicaid