Healthcare Provider Details

I. General information

NPI: 1821423484
Provider Name (Legal Business Name): KATHERINE G LOTT AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2013
Last Update Date: 01/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6295 OLD CANTON RD APT 23B
JACKSON MS
39211-2908
US

IV. Provider business mailing address

6295 OLD CANTON RD APT 23B
JACKSON MS
39211-2908
US

V. Phone/Fax

Practice location:
  • Phone: 601-463-0676
  • Fax:
Mailing address:
  • Phone: 601-463-0676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR876755
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR876755
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: