Provider Demographics
NPI:1730748633
Name:WARREN, MAMIE (RN, MSN, MMED)
Entity type:Individual
Prefix:
First Name:MAMIE
Middle Name:
Last Name:WARREN
Suffix:
Gender:F
Credentials:RN, MSN, MMED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 611
Mailing Address - Street 2:
Mailing Address - City:HOLLANDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38748-0611
Mailing Address - Country:US
Mailing Address - Phone:662-347-2513
Mailing Address - Fax:662-807-5052
Practice Address - Street 1:206 HIGHWAY 12 E
Practice Address - Street 2:
Practice Address - City:HOLLANDALE
Practice Address - State:MS
Practice Address - Zip Code:38748-3822
Practice Address - Country:US
Practice Address - Phone:662-347-2513
Practice Address - Fax:662-807-5052
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR745796163WC1600X, 163WC1500X, 163WS0200X, 174H00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WS0200XNursing Service ProvidersRegistered NurseSchool
No174H00000XOther Service ProvidersHealth Educator