Provider Demographics
NPI:1740350628
Name:HERNANDO FAMILY MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:HERNANDO FAMILY MEDICAL CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-429-4988
Mailing Address - Street 1:2778 HIGHWAY 51 S
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-9403
Mailing Address - Country:US
Mailing Address - Phone:662-429-4988
Mailing Address - Fax:662-429-4966
Practice Address - Street 1:2778 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-9403
Practice Address - Country:US
Practice Address - Phone:662-429-4988
Practice Address - Fax:662-429-4966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS363LF0000X, 363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000735805Medicaid
MS00735805Medicaid
MSC03564Medicare ID - Type UnspecifiedCAHABA