Provider Demographics
NPI:1063911485
Name:FAITH FAMILY CLINIC OF BOONEVILLE
Entity type:Organization
Organization Name:FAITH FAMILY CLINIC OF BOONEVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:MS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:JANZEN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-728-0162
Mailing Address - Street 1:2209 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-7734
Mailing Address - Country:US
Mailing Address - Phone:662-728-0162
Mailing Address - Fax:662-728-0326
Practice Address - Street 1:2209 N 2ND ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-7734
Practice Address - Country:US
Practice Address - Phone:662-728-0162
Practice Address - Fax:662-728-0326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR871985261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05850217Medicaid