Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | AT0843 | MS |
Y | 213ES0000X | Sports Medicine | AT0843 | MS |
NPI | 1285142935 |
---|---|
Provider Name | Cassandra Alexis Deforrest |
First Address | Brandon, MS 39042-9579 |
Second Address | Brandon, MS 39042-3169 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/01/2018 |
Last Update Date | 16/01/2018 |