Provider Demographics
NPI:1477526499
Name:GIST, JENNICE H
Entity Type:Individual
Prefix:
First Name:JENNICE
Middle Name:H
Last Name:GIST
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:PO BOX 73709
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30271-3709
Mailing Address - Country:US
Mailing Address - Phone:770-251-2060
Mailing Address - Fax:678-854-9235
Practice Address - Street 1:136 SOUTHGATE BLVD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-8035
Practice Address - Country:US
Practice Address - Phone:678-289-6483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN134488367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA664068606BMedicaid
GA43BBBLVMedicare PIN
GAQ05682Medicare UPIN