Provider Demographics
NPI:1831130715
Name:GADDIS, RUTH C (FNP)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:C
Last Name:GADDIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:MS
Mailing Address - Zip Code:39342-0520
Mailing Address - Country:US
Mailing Address - Phone:601-646-7700
Mailing Address - Fax:888-735-7202
Practice Address - Street 1:330 N BROAD ST
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-3508
Practice Address - Country:US
Practice Address - Phone:601-469-4771
Practice Address - Fax:601-469-4724
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR717142363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126171Medicaid
S89094Medicare UPIN
MS00126171Medicaid