Provider Demographics
NPI:1437621323
Name:GANISON, QUEENEICE BOYETTE (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:QUEENEICE
Middle Name:BOYETTE
Last Name:GANISON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2492 MOURNING DOVE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-8121
Mailing Address - Country:US
Mailing Address - Phone:662-822-3150
Mailing Address - Fax:
Practice Address - Street 1:205 S DELTA ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-4420
Practice Address - Country:US
Practice Address - Phone:662-822-3150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902219363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner