Provider Demographics
NPI:1750480307
Name:ROLISON, CONNIE R (WHNP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:R
Last Name:ROLISON
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4577 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2516
Mailing Address - Country:US
Mailing Address - Phone:228-864-2752
Mailing Address - Fax:
Practice Address - Street 1:4577 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2516
Practice Address - Country:US
Practice Address - Phone:228-864-2752
Practice Address - Fax:228-214-4206
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR852304363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0125772Medicaid
MS500001099Medicare PIN
MSP67787Medicare UPIN