Provider Demographics
NPI:1841332350
Name:HARRELL, ROSEMARY T
Entity type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:T
Last Name:HARRELL
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 1:19395 HIGHWAY 14
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MS
Mailing Address - Zip Code:39341-9213
Mailing Address - Country:US
Mailing Address - Phone:662-726-4211
Mailing Address - Fax:
Practice Address - Street 1:19395 HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MS
Practice Address - Zip Code:39341-9213
Practice Address - Country:US
Practice Address - Phone:662-726-4211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS113990363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123958Medicaid
MSQ06250Medicare UPIN
MS500001417Medicare ID - Type UnspecifiedMEDICARE