Provider Demographics
NPI:1104036177
Name:SPREAFICO, MARY ELIZABETH (FNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:SPREAFICO
Suffix:
Gender:F
Credentials:FNP
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 2106
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2106
Mailing Address - Country:US
Mailing Address - Phone:601-703-4282
Mailing Address - Fax:601-703-4597
Practice Address - Street 1:24345 HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MS
Practice Address - Zip Code:39365-8575
Practice Address - Country:US
Practice Address - Phone:601-774-8211
Practice Address - Fax:601-774-8589
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865728363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06427823Medicaid