1871726182 NPI number — MRS. GWENDOLYN PITCOCK SHIRLEY FNP

Table of content: DR. JOSEPH M SHARKEY M.D. (NPI 1649277435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871726182 NPI number — MRS. GWENDOLYN PITCOCK SHIRLEY FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIRLEY
Provider First Name:
GWENDOLYN
Provider Middle Name:
PITCOCK
Provider Name Prefix Text:
MRS.
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871726182
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3402 TOCOWA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COURTLAND
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38620-9213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-563-3994
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2149 STATELINE RD W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-1222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-342-1112
Provider Business Practice Location Address Fax Number:
662-342-1116
Provider Enumeration Date:
09/02/2009

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:  R858450 , 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)





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