Provider Demographics
NPI:1780847830
Name:GANDY, CHRISTIE L (NP)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:L
Last Name:GANDY
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 1:971 LAKELAND DR
Mailing Address - Street 2:SUITE 854
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4643
Mailing Address - Country:US
Mailing Address - Phone:601-981-2825
Mailing Address - Fax:601-981-2827
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 854
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-981-2825
Practice Address - Fax:601-981-2827
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR851382363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09221018Medicaid
MS09221018Medicaid
MS512I500455Medicare PIN
MS30250I7070Medicare PIN