Provider Demographics
NPI:1750452595
Name:WALDROP, DAWN MICHELE (CFO)
Entity Type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:MICHELE
Last Name:WALDROP
Suffix:
Gender:F
Credentials:CFO
Other - Prefix:MRS
Other - First Name:DAWN
Other - Middle Name:M
Other - Last Name:WALDROP
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CFO
Mailing Address - Street 1:4155 HIGHWAY 178 W
Mailing Address - Street 2:P.O. BOX 254
Mailing Address - City:RED BANKS
Mailing Address - State:MS
Mailing Address - Zip Code:38661-9603
Mailing Address - Country:US
Mailing Address - Phone:662-551-2377
Mailing Address - Fax:662-551-2372
Practice Address - Street 1:4155 HIGHWAY 178 W
Practice Address - Street 2:
Practice Address - City:RED BANKS
Practice Address - State:MS
Practice Address - Zip Code:38661-9603
Practice Address - Country:US
Practice Address - Phone:662-551-2377
Practice Address - Fax:662-551-2372
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARFO02225332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06902890Medicaid
TN4582370Medicaid
MS5465570001Medicare NSC