Basic Information
| Provider Information | |||||||||
| NPI: | 1689996282 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FIVEASH | ||||||||
| FirstName: | PHYLLIS | ||||||||
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| Credential: | CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 ALCORN DR | ||||||||
| Address2: | STE 2C | ||||||||
| City: | CORINTH | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388349073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016830055 | ||||||||
| FaxNumber: | 9016859718 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 STATE DR | ||||||||
| Address2: | |||||||||
| City: | CORINTH | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388349324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622863694 | ||||||||
| FaxNumber: | 9016859718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2010 | ||||||||
| LastUpdateDate: | 05/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R871915 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 05170544 | 05 | MS | MEDICAID |