Provider Demographics
NPI:1396234498
Name:PRIDE, DEBORAH LATRICE
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LATRICE
Last Name:PRIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4365 HIGHWAY 51 S
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-2533
Mailing Address - Country:US
Mailing Address - Phone:662-562-3049
Mailing Address - Fax:877-855-7540
Practice Address - Street 1:4365 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-2533
Practice Address - Country:US
Practice Address - Phone:662-562-3049
Practice Address - Fax:877-855-7540
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS800280913172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS8859Medicaid