Provider Demographics
NPI:1720676422
Name:PURNELL, MABLE C (CCMA, MEDICAL DATA)
Entity Type:Individual
Prefix:
First Name:MABLE
Middle Name:C
Last Name:PURNELL
Suffix:
Gender:F
Credentials:CCMA, MEDICAL DATA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1192 HARVEY CIR
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:MS
Mailing Address - Zip Code:39041-9471
Mailing Address - Country:US
Mailing Address - Phone:601-946-3926
Mailing Address - Fax:
Practice Address - Street 1:2460 TERRY RD STE 350
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-5792
Practice Address - Country:US
Practice Address - Phone:601-946-3926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSZ3X2A4K5251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS84-5046661OtherPRIVATE INSURANCE
MS84-5046661Medicaid