Provider Demographics
NPI:1376871160
Name:SHULL, GRETCHEN S (ANP)
Entity Type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:S
Last Name:SHULL
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-622-1744
Mailing Address - Fax:601-622-1744
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:UNIVERSITY PHYSICIANS
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-1384
Practice Address - Fax:601-815-3322
Is Sole Proprietor?:No
Enumeration Date:2009-12-07
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR870219363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00672357Medicaid
MS00672357Medicaid
MSP01676200Medicare PIN