1639522196 NPI number — MRS. GENNITHA MARIE MCLEOD FNP

Table of content: MRS. GENNITHA MARIE MCLEOD FNP (NPI 1639522196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639522196 NPI number — MRS. GENNITHA MARIE MCLEOD FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCLEOD
Provider First Name:
GENNITHA
Provider Middle Name:
MARIE
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:
JACKSON RICE
Provider Other First Name:
GENNITHA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1639522196
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 HOLMES DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-403-3534
Provider Business Mailing Address Fax Number:
256-403-3541

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 HOLMES DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-403-3534
Provider Business Practice Location Address Fax Number:
256-403-3541
Provider Enumeration Date:
07/20/2016

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:  RN237968 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003178587A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 202503I184 . This is a "MEDICARE PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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