Provider Demographics
NPI:1295596575
Name:BOOKER, MARY MANNING (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MANNING
Last Name:BOOKER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2686 PINNACLE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6595
Mailing Address - Country:US
Mailing Address - Phone:662-306-3081
Mailing Address - Fax:
Practice Address - Street 1:2686 PINNACLE DR
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-6595
Practice Address - Country:US
Practice Address - Phone:662-306-3081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR887767163WP0808X
MS906387363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health