Provider Demographics
NPI:1669412052
Name:HARTER, MARY ELIZABETH (FNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:HARTER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:HANDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:4770 AMOCO DR
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563-9627
Mailing Address - Country:US
Mailing Address - Phone:228-474-9511
Mailing Address - Fax:228-474-9506
Practice Address - Street 1:4770 AMOCO DR
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-9627
Practice Address - Country:US
Practice Address - Phone:228-474-9511
Practice Address - Fax:228-474-9506
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALI-085233363L00000X
MNR213146-9363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALQ45468Medicare UPIN
AL1972698199OtherMEDICARE GROUP PAYEE NPI
AL011855OtherMEDICARE GROUP NUMBER
AL051532300HANMedicare ID - Type Unspecified
AL891010740Medicaid