Provider Demographics
NPI:1477007425
Name:GARY, MARKITA SHERISE
Entity Type:Individual
Prefix:
First Name:MARKITA
Middle Name:SHERISE
Last Name:GARY
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 1:60 PROCTOR ST
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:MS
Mailing Address - Zip Code:38683-9623
Mailing Address - Country:US
Mailing Address - Phone:731-212-0457
Mailing Address - Fax:
Practice Address - Street 1:60 PROCTOR ST
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:MS
Practice Address - Zip Code:38683
Practice Address - Country:US
Practice Address - Phone:731-212-0457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health