Provider Demographics
NPI:1619174299
Name:HILL, GWENDOLYN H (FNP)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:H
Last Name:HILL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 GLOSTER CREEK VLG STE A2
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4749
Mailing Address - Country:US
Mailing Address - Phone:662-620-6800
Mailing Address - Fax:662-377-2403
Practice Address - Street 1:499 GLOSTER CREEK VLG STE A2
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4749
Practice Address - Country:US
Practice Address - Phone:662-620-6800
Practice Address - Fax:662-377-2403
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR858885363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02173757Medicaid