Provider Demographics
NPI:1578261095
Name:CERTAIN, DAIWANA D
Entity Type:Individual
Prefix:
First Name:DAIWANA
Middle Name:D
Last Name:CERTAIN
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 1601
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-1601
Mailing Address - Country:US
Mailing Address - Phone:601-347-2928
Mailing Address - Fax:
Practice Address - Street 1:713 CHARLOTTE DR
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-4903
Practice Address - Country:US
Practice Address - Phone:601-347-2928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS800340601343900000X
347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)