Provider Demographics
NPI:1144831140
Name:PRUDHOMME, MANIVANH A (MSN, FNP-BC, AGACNP-)
Entity type:Individual
Prefix:
First Name:MANIVANH
Middle Name:A
Last Name:PRUDHOMME
Suffix:
Gender:F
Credentials:MSN, FNP-BC, AGACNP-
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 HIGHWAY 61 N
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183
Mailing Address - Country:US
Mailing Address - Phone:601-456-2277
Mailing Address - Fax:601-456-2622
Practice Address - Street 1:2011 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-3918
Practice Address - Country:US
Practice Address - Phone:014-562-2776
Practice Address - Fax:601-456-2622
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904068363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily