Provider Demographics
NPI:1760049829
Name:REDMOND-WILLS, PANDORA (RN)
Entity Type:Individual
Prefix:
First Name:PANDORA
Middle Name:
Last Name:REDMOND-WILLS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:PANDORA
Other - Middle Name:
Other - Last Name:REDMOND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 4580
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38704-4580
Mailing Address - Country:US
Mailing Address - Phone:662-822-1924
Mailing Address - Fax:662-335-5580
Practice Address - Street 1:749 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-4108
Practice Address - Country:US
Practice Address - Phone:662-335-5554
Practice Address - Fax:662-335-5580
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QA0600X, 372600000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07331397Medicaid
MS08679792Medicaid
MS06908787Medicaid