Provider Demographics
NPI:1689958902
Name:WINDHAM, MANDY H (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:H
Last Name:WINDHAM
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MISS
Other - First Name:MANDY
Other - Middle Name:NICOLE
Other - Last Name:HATTAWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:120 STONE CREEK BLVD
Mailing Address - Street 2:STE 500
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8205
Mailing Address - Country:US
Mailing Address - Phone:769-235-2941
Mailing Address - Fax:601-939-2211
Practice Address - Street 1:1746 C MS STATE HWY 1 SOUTH
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-6304
Practice Address - Country:US
Practice Address - Phone:662-743-9809
Practice Address - Fax:662-743-9811
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872654363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR872654OtherLICENSE