Provider Demographics
NPI:1386781151
Name:GRIFFIN, MANDA SUE (DNP)
Entity type:Individual
Prefix:MRS
First Name:MANDA
Middle Name:SUE
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 THIRD AVENUE HIGHWAY 32 WEST
Mailing Address - Street 2:
Mailing Address - City:HOULKA
Mailing Address - State:MS
Mailing Address - Zip Code:38850-9004
Mailing Address - Country:US
Mailing Address - Phone:662-568-2013
Mailing Address - Fax:662-568-2023
Practice Address - Street 1:400 THIRD AVENUE HIGHWAY 32 WEST
Practice Address - Street 2:
Practice Address - City:HOULKA
Practice Address - State:MS
Practice Address - Zip Code:38850-9004
Practice Address - Country:US
Practice Address - Phone:662-568-2013
Practice Address - Fax:662-568-2023
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR850148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04506555Medicaid
MSR850148OtherFNP