Provider Demographics
NPI:1407516909
Name:KILLINGSWORTH, GLORIA JEAN
Entity Type:Individual
Prefix:MISS
First Name:GLORIA
Middle Name:JEAN
Last Name:KILLINGSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 MAGNOLIA ST.
Mailing Address - Street 2:
Mailing Address - City:HAZELHURST
Mailing Address - State:MS
Mailing Address - Zip Code:39083
Mailing Address - Country:US
Mailing Address - Phone:601-291-0852
Mailing Address - Fax:
Practice Address - Street 1:221 MAGNOLIA ST.
Practice Address - Street 2:
Practice Address - City:HAZELHURST
Practice Address - State:MS
Practice Address - Zip Code:39083
Practice Address - Country:US
Practice Address - Phone:601-291-0852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1305053374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide