Provider Demographics
NPI:1114403268
Name:GINN, KATHERINE PUCKETT (NP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:PUCKETT
Last Name:GINN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23457
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3457
Mailing Address - Country:US
Mailing Address - Phone:601-200-6897
Mailing Address - Fax:601-200-5899
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-200-6897
Practice Address - Fax:601-200-5899
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902808363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS688710OtherMEDICARE
MS08220070Medicaid
MSP02359034OtherRAILROAD MEDICARE