Provider Demographics
NPI:1912480328
Name:REED, CLIFTON DEWAYNE
Entity type:Individual
Prefix:
First Name:CLIFTON
Middle Name:DEWAYNE
Last Name:REED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W PEELER AVE
Mailing Address - Street 2:
Mailing Address - City:SHAW
Mailing Address - State:MS
Mailing Address - Zip Code:38773-8710
Mailing Address - Country:US
Mailing Address - Phone:662-754-3304
Mailing Address - Fax:662-754-3301
Practice Address - Street 1:112 W PEELER AVE
Practice Address - Street 2:
Practice Address - City:SHAW
Practice Address - State:MS
Practice Address - Zip Code:38773-8710
Practice Address - Country:US
Practice Address - Phone:662-754-3304
Practice Address - Fax:662-754-3301
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR877471363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily