Provider Demographics
NPI:1588015903
Name:CECCORULLI, TINA J
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:J
Last Name:CECCORULLI
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 1:3616 HOSPITAL ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-4117
Mailing Address - Country:US
Mailing Address - Phone:228-872-7684
Mailing Address - Fax:228-762-7109
Practice Address - Street 1:3890 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5803
Practice Address - Country:US
Practice Address - Phone:228-872-6291
Practice Address - Fax:228-875-3385
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS901580363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily