Provider Demographics
NPI:1457533424
Name:SMITH, LORETTA JEAN (FNP)
Entity Type:Individual
Prefix:MS
First Name:LORETTA
Middle Name:JEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:LORETTA
Other - Middle Name:JEAN
Other - Last Name:FILLYAW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 156
Mailing Address - Street 2:
Mailing Address - City:GUNTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:38849-0156
Mailing Address - Country:US
Mailing Address - Phone:662-348-2002
Mailing Address - Fax:662-348-2001
Practice Address - Street 1:571 MITCHELL ROAD
Practice Address - Street 2:
Practice Address - City:GUNTOWN
Practice Address - State:MS
Practice Address - Zip Code:38849
Practice Address - Country:US
Practice Address - Phone:662-348-2002
Practice Address - Fax:662-348-2001
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-03
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR855649363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00631368Medicaid