Provider Demographics
NPI:1659350700
Name:SPEYRER, MARY PENLAND (NP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:PENLAND
Last Name:SPEYRER
Suffix:
Gender:F
Credentials:NP
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 2563
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39505-2563
Mailing Address - Country:US
Mailing Address - Phone:228-865-9898
Mailing Address - Fax:228-863-5616
Practice Address - Street 1:9344 THREE RIVERS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4268
Practice Address - Country:US
Practice Address - Phone:228-865-9898
Practice Address - Fax:228-863-5616
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03039363LA2100X
MS901778363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS558986YNL6OtherMEDICARE
LA5000023389OtherRAILROAD MEDICARE
LA232781OtherWELLCARE
MS01200718Medicaid
LA1533173Medicaid
LA1533173Medicaid
LA232781OtherWELLCARE
LAS45552Medicare UPIN