Provider Demographics
NPI:1174298293
Name:CORROTHERS ROYAL, GWENDOLYN (FNP-C)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:CORROTHERS ROYAL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-2751
Mailing Address - Country:US
Mailing Address - Phone:601-262-2922
Mailing Address - Fax:
Practice Address - Street 1:919 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-2751
Practice Address - Country:US
Practice Address - Phone:601-262-2922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904875363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily