Healthcare Provider Details

I. General information

NPI: 1225521982
Provider Name (Legal Business Name): GABRIELLE DESCHAMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1687 FIRETOWER RD
KILN MS
39556-6385
US

IV. Provider business mailing address

1687 FIRETOWER RD
KILN MS
39556-6385
US

V. Phone/Fax

Practice location:
  • Phone: 228-229-7698
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902652
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: