Healthcare Provider Details

I. General information

NPI: 1942699988
Provider Name (Legal Business Name): BETH ANN GRUZINSKAS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2015
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BROAD AVE STE 330
GULFPORT MS
39501-2464
US

IV. Provider business mailing address

7 WOOD PL
BAY ST LOUIS MS
39520-2836
US

V. Phone/Fax

Practice location:
  • Phone: 228-575-1234
  • Fax: 228-867-4828
Mailing address:
  • Phone: 228-216-5737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR853237
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: