Provider Demographics
NPI:1689096505
Name:GRESSETT, WENDY D (NP-C)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:D
Last Name:GRESSETT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:D
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:1120 E MAIN ST STE 24
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-2300
Mailing Address - Country:US
Mailing Address - Phone:601-781-8677
Mailing Address - Fax:601-676-0550
Practice Address - Street 1:9431 EASTSIDE DRIVE EXT STE B
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MS
Practice Address - Zip Code:39345-8072
Practice Address - Country:US
Practice Address - Phone:601-635-2990
Practice Address - Fax:601-676-0550
Is Sole Proprietor?:No
Enumeration Date:2014-01-11
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR862286363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05822327Medicaid