Provider Demographics
NPI:1891183208
Name:RUSH, KATIE DALEY (CFNP)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:DALEY
Last Name:RUSH
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 ROSE ST.
Mailing Address - Street 2:STE. A
Mailing Address - City:PRENTISS
Mailing Address - State:MS
Mailing Address - Zip Code:39474
Mailing Address - Country:US
Mailing Address - Phone:601-792-1223
Mailing Address - Fax:601-651-6076
Practice Address - Street 1:1014 ROSE ST.
Practice Address - Street 2:STE. A
Practice Address - City:PRENTISS
Practice Address - State:MS
Practice Address - Zip Code:39474
Practice Address - Country:US
Practice Address - Phone:601-792-1223
Practice Address - Fax:601-651-6076
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR873357363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily