Healthcare Provider Details

I. General information

NPI: 1578301735
Provider Name (Legal Business Name): MRS. ELLIE REBECCA ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2024
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 MEDICAL PARK DR STE 200
BILOXI MS
39532-2105
US

IV. Provider business mailing address

1688 PENNSYLVANIA PL
MOBILE AL
36695-4302
US

V. Phone/Fax

Practice location:
  • Phone: 228-392-7429
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number937
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: