Provider Demographics
NPI:1558636282
Name:STURDIVANT, GRACE GORE (AUD)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:GORE
Last Name:STURDIVANT
Suffix:
Gender:F
Credentials:AUD
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:601-815-6000
Mailing Address - Fax:601-984-5085
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-6000
Practice Address - Fax:601-984-5085
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA3608231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07203769Medicaid
MSP01266932OtherRAILROAD MEDICARE
MS07203769Medicaid
MS302I643081Medicare PIN