1205896842 NPI number — MS. LORRAINE GADDIS CFNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205896842 NPI number — MS. LORRAINE GADDIS CFNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GADDIS
Provider First Name:
LORRAINE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CFNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HAMM
Provider Other First Name:
LORRAINE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CFNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205896842
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23666
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39225-3666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-200-4749
Provider Business Mailing Address Fax Number:
601-200-5929

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
127 GRANDVIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39110-7595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-853-0203
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2006

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: 363L00000X , with the licence number:  R741224 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03282005 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com