Provider Demographics
NPI:1194745315
Name:MAHAFFEY, MICHELE BRYANT (FNP)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:BRYANT
Last Name:MAHAFFEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:BRYANT
Other - Last Name:COWARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 667
Mailing Address - Street 2:1014 ROSE STREET SUITE A
Mailing Address - City:PRENTISS
Mailing Address - State:MS
Mailing Address - Zip Code:39474-0667
Mailing Address - Country:US
Mailing Address - Phone:601-792-2200
Mailing Address - Fax:601-792-2345
Practice Address - Street 1:1014 ROSE ST
Practice Address - Street 2:SUITE A
Practice Address - City:PRENTISS
Practice Address - State:MS
Practice Address - Zip Code:39474-5271
Practice Address - Country:US
Practice Address - Phone:601-792-2200
Practice Address - Fax:601-792-2345
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR667552363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05851817Medicaid
MS12117492OtherCAQH
MS05851817Medicaid
MS12117492OtherCAQH