Provider Demographics
NPI:1649790437
Name:MAYS MEDICAL WELLNESS, LLC
Entity type:Organization
Organization Name:MAYS MEDICAL WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MAYS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-655-0456
Mailing Address - Street 1:3964 GOODMAN RD E STE 128
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6494
Mailing Address - Country:US
Mailing Address - Phone:662-655-0456
Mailing Address - Fax:662-655-0457
Practice Address - Street 1:3964 GOODMAN RD E STE 128
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-6494
Practice Address - Country:US
Practice Address - Phone:662-655-0456
Practice Address - Fax:662-655-0457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-22
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363LP2300X
MS261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS001870621Medicaid