Provider Demographics
NPI:1548047970
Name:KUNTRY NURSE, LLC
Entity type:Organization
Organization Name:KUNTRY NURSE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAMETRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:601-310-9784
Mailing Address - Street 1:1252 WEST GOVERNMENT STREET
Mailing Address - Street 2:P.O. BOX 2336
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39043-2336
Mailing Address - Country:US
Mailing Address - Phone:601-310-9784
Mailing Address - Fax:
Practice Address - Street 1:232 MARKET STREET
Practice Address - Street 2:SUITE 259
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-3339
Practice Address - Country:US
Practice Address - Phone:601-310-9784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-11
Last Update Date:2024-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty