Provider Demographics
NPI:1386168730
Name:HINES, NETTIE (OD)
Entity type:Individual
Prefix:
First Name:NETTIE
Middle Name:
Last Name:HINES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 TREETOPS BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-7645
Mailing Address - Country:US
Mailing Address - Phone:601-519-4466
Mailing Address - Fax:601-374-5737
Practice Address - Street 1:1006 TREETOPS BLVD STE 105
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-7645
Practice Address - Country:US
Practice Address - Phone:601-519-4466
Practice Address - Fax:601-374-5737
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS956152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08753003Medicaid
MS956OtherOPTOMETRY STATE LICENSE