Healthcare Provider Details

I. General information

NPI: 1962321778
Provider Name (Legal Business Name): MADELEINE GAUL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3317 PEMBERTON SQUARE BLVD
VICKSBURG MS
39180-5578
US

IV. Provider business mailing address

1506 CHAMBERS ST
VICKSBURG MS
39180-3922
US

V. Phone/Fax

Practice location:
  • Phone: 601-636-1173
  • Fax: 601-630-9674
Mailing address:
  • Phone: 601-415-0529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number917750
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number908649
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: