1679740997 NPI number — NEVA JO PETTIGREW FNP

Table of content: NEVA JO PETTIGREW FNP (NPI 1679740997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679740997 NPI number — NEVA JO PETTIGREW FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETTIGREW
Provider First Name:
NEVA
Provider Middle Name:
JO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STRICKLAND
Provider Other First Name:
NEVA
Provider Other Middle Name:
JO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679740997
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1314 19TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39301-4116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-703-4282
Provider Business Mailing Address Fax Number:
601-703-4597

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1710 14TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39301-4140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-703-1485
Provider Business Practice Location Address Fax Number:
601-703-1488
Provider Enumeration Date:
05/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R684899 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01758833 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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