Healthcare Provider Details

I. General information

NPI: 1912321175
Provider Name (Legal Business Name): GWENDOLYN SPRAYBERRY LORDEON MSN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2014
Last Update Date: 02/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 VAN DORN ST
GRENADA MS
38901-4738
US

IV. Provider business mailing address

705 COUNTY ROAD 380
CALHOUN CITY MS
38916-7111
US

V. Phone/Fax

Practice location:
  • Phone: 662-226-0325
  • Fax:
Mailing address:
  • Phone: 662-414-6271
  • Fax: 662-227-2296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR765701
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: