Basic Information
| Provider Information | |||||||||
| NPI: | 1710256037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERBERT | ||||||||
| FirstName: | FANIKA | ||||||||
| MiddleName: | SHUNTAE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ADAMS | ||||||||
| OtherFirstName: | FANIKA | ||||||||
| OtherMiddleName: | SHUNTAE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 101 HOLMAN ST | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390592582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012011130 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019841000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2011 | ||||||||
| LastUpdateDate: | 12/14/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WM0705X | R882847 | MS | Y | Nursing Service Providers | Registered Nurse | Medical-Surgical |
No ID Information.