Provider Demographics
NPI:1821423484
Name:LOTT, KATHERINE G (AGACNP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:G
Last Name:LOTT
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6295 OLD CANTON RD
Mailing Address - Street 2:APT 23B
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2908
Mailing Address - Country:US
Mailing Address - Phone:601-463-0676
Mailing Address - Fax:
Practice Address - Street 1:6295 OLD CANTON RD
Practice Address - Street 2:APT 23B
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2908
Practice Address - Country:US
Practice Address - Phone:601-463-0676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-13
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR876755363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01928036Medicaid
MS320694YJ5DMedicare PIN