Healthcare Provider Details

I. General information

NPI: 1093635690
Provider Name (Legal Business Name): GLORIA MCGAUGHY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GLORIA MCGAUGHY

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 LANERE DR
OLIVE BRANCH MS
38654-2343
US

IV. Provider business mailing address

1155 LANERE DR
OLIVE BRANCH MS
38654-2343
US

V. Phone/Fax

Practice location:
  • Phone: 501-772-5424
  • Fax:
Mailing address:
  • Phone: 501-772-5424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number908589
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: