Provider Demographics
NPI:1356713903
Name:FLOYD, MITZI NICHOLS (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MITZI
Middle Name:NICHOLS
Last Name:FLOYD
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:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39043-0088
Mailing Address - Country:US
Mailing Address - Phone:601-825-8800
Mailing Address - Fax:601-824-1681
Practice Address - Street 1:613 MARQUETTE RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-3038
Practice Address - Country:US
Practice Address - Phone:601-825-8800
Practice Address - Fax:601-824-1681
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS862958363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02785041Medicaid
MS02623831Medicaid