Healthcare Provider Details

I. General information

NPI: 1225091192
Provider Name (Legal Business Name): KEESLER MEDICAL CENTER 81ST MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 FISHER ST STE 109
KEESLER AFB MS
39534-2508
US

IV. Provider business mailing address

2620 LEJUENE DR APT 10204
BILOXI MS
39531-3740
US

V. Phone/Fax

Practice location:
  • Phone: 228-377-6920
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number0001107341
License Number StateVA

VIII. Authorized Official

Name: SHERRI LYNETTE SAUNDERS-GOLDSON
Title or Position: WOMEN'S HEALTH NURSE PRACTITIONER
Credential:
Phone: 228-377-6989