Healthcare Provider Details

I. General information

NPI: 1871726182
Provider Name (Legal Business Name): GWENDOLYN PITCOCK SHIRLEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 02/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2149 STATELINE RD W
SOUTHAVEN MS
38671-1222
US

IV. Provider business mailing address

3402 TOCOWA RD
COURTLAND MS
38620-9213
US

V. Phone/Fax

Practice location:
  • Phone: 662-342-1112
  • Fax: 662-342-1116
Mailing address:
  • Phone: 662-563-3994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR858450
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: