Provider Demographics
NPI:1457763336
Name:HARRISON, NANCY SALLOUM (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:SALLOUM
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 MILLSAPS DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1328
Practice Address - Country:US
Practice Address - Phone:601-288-7500
Practice Address - Fax:601-579-5240
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25183207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09200033Medicaid