Fast Pace Mississippi, PLLC

Primary specialty

Rural Health Clinic/CenterTaxonomy code 261QR1300X

Legal business name

FAST PACE MISSISSIPPI, PLLC

Practice address

305 Hill St
Ellisville, MS 39437-2521

Phone

(601) 800-0118

NPI assigned

Nov 22, 2021

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Sydni Clemmons

Title

Credentialing Manager

Phone

(901) 351-1791

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MS

Enrollment records 1

Rural health clinic certification: CCN A53809

Legal name

FAST PACE MISSISSIPPI PLLC

Doing business as

FAST PACE HEALTH

Certification status

Active

Provider type (POS)

Rural health clinic

Participating since

Feb 1, 2022

Last certification

Feb 1, 2022

Ownership / control type

1B

Organization structure

OtherProprietary

Incorporated

Sep 15, 2017 in MS

Enrollment address

305 Hill St
Ellisville, MS 39437-2521

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

• Fast Pace Mississippi, PLLC

  • Rural Health Clinic/Center
  • Kosciusko, MS
  • NPI 1851050579

  O20211209002223

  Same enrollment

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

• Dana Kay Martin, C.F.N.P.

  • Family Nurse Practitioner
  • Selmer, TN
  • NPI 1497781454

  5% Or Greater Direct Ownership Interest

  CMS ownership

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1637539200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1637539200000",
    "number": "1740947019",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 306415",
            "city": "NASHVILLE",
            "state": "TN",
            "postal_code": "372306415"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "305 HILL ST",
            "city": "ELLISVILLE",
            "state": "MS",
            "postal_code": "394372521",
            "telephone_number": "601-800-0118"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAST PACE MISSISSIPPI, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-11-22",
        "last_updated": "2021-11-22",
        "certification_date": "2021-11-22",
        "status": "A",
        "authorized_official_last_name": "CLEMMONS",
        "authorized_official_first_name": "SYDNI",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "901-351-1791"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Lisa Elmore
• Jeri S England, FNP
• Uniqua Evans, CCSS
• Shawnkita Everett, RN
• Family Health Center Inc
• Ashley Floyd, WHNP
• Mary Fowler
• Porosha Gaines, IDD WAIVER SERVICES
• Shannon L Goldsmith, D.O.
• Shirley Griffin, PCCSS

• Rural Health Clinic/Center in Ellisville, MS
• Providers in Ellisville, MS by specialty
• Rural Health Clinic/Center in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 22, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.