1316253115 NPI number — CARON GIBSON HENDERSON ANP

Table of content: CARON GIBSON HENDERSON ANP (NPI 1316253115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316253115 NPI number — CARON GIBSON HENDERSON ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
CARON
Provider Middle Name:
GIBSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GIBSON
Provider Other First Name:
CARON
Provider Other Middle Name:
CATHLEEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316253115
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEAKESVILLE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39451-0160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-394-2381
Provider Business Mailing Address Fax Number:
601-394-5715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1616 WILLIAMS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEAKESVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39451-5622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-394-2381
Provider Business Practice Location Address Fax Number:
601-394-5715
Provider Enumeration Date:
08/31/2010

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: 363LA2200X , with the licence number:  R873868 , 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: 09228250 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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