Provider Demographics
NPI:1740039114
Name:HUMPHREYS, SALLIE
Entity type:Individual
Prefix:
First Name:SALLIE
Middle Name:
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 COUNTY ROAD 180
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38828-9268
Mailing Address - Country:US
Mailing Address - Phone:662-507-5146
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program