=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154669786
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAKENDRIA ZOLLICOFFER WHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2013
-----------------------------------------------------
Last Update Date | 12/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3502 W NORTHSIDE DR
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39213-4454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-362-5321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 BRITTON CIR
-----------------------------------------------------
City | FLOWOOD
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39232-8109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-382-5634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | R878700
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------