Provider Demographics
NPI:1669576989
Name:KING, THERESA RENEE (RN, CFNP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:RENEE
Last Name:KING
Suffix:
Gender:F
Credentials:RN, CFNP
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:RENEE
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, CFNP
Mailing Address - Street 1:PO BOX 1805
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39043-1805
Mailing Address - Country:US
Mailing Address - Phone:601-826-5500
Mailing Address - Fax:601-420-5299
Practice Address - Street 1:427 HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2350
Practice Address - Country:US
Practice Address - Phone:601-826-5500
Practice Address - Fax:601-420-5299
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR873560363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02572058Medicaid
MSP69909Medicare UPIN