Healthcare Provider Details

I. General information

NPI: 1700779105
Provider Name (Legal Business Name): EMILY CATHERINE GANDENBERGER CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 02/28/2026
Certification Date: 02/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 BROOKWAY BLVD
BROOKHAVEN MS
39601-3267
US

IV. Provider business mailing address

439 MADISON OAKS DR
MADISON MS
39110-9495
US

V. Phone/Fax

Practice location:
  • Phone: 601-896-3898
  • Fax:
Mailing address:
  • Phone: 601-835-1062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number907889
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: