Healthcare Provider Details

I. General information

NPI: 1801987870
Provider Name (Legal Business Name): PRIMESOURCE NURSING SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4906 KENDALL AVE
GULFPORT MS
39507-4409
US

IV. Provider business mailing address

PO BOX 6705
GULFPORT MS
39506-6705
US

V. Phone/Fax

Practice location:
  • Phone: 228-865-1330
  • Fax: 228-865-1331
Mailing address:
  • Phone: 228-865-1330
  • Fax: 228-865-1331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. JANA LEIGH PLAUCHE
Title or Position: PRESIDENT
Credential:
Phone: 228-865-1330