Provider Demographics
NPI:1861499592
Name:RENWICK, PRISCILLA M (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:PRISCILLA
Middle Name:M
Last Name:RENWICK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
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 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-863-4000
Mailing Address - Fax:228-863-4003
Practice Address - Street 1:4333 15TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2525
Practice Address - Country:US
Practice Address - Phone:228-863-4000
Practice Address - Fax:228-863-4003
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR551635363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0126456Medicaid
MS500001144Medicare ID - Type Unspecified
MS0126456Medicaid