Provider Demographics
NPI:1891711784
Name:RACEY, JEANNINE A (CGNP)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:A
Last Name:RACEY
Suffix:
Gender:F
Credentials:CGNP
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 6705
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-6705
Mailing Address - Country:US
Mailing Address - Phone:228-865-1330
Mailing Address - Fax:228-865-1331
Practice Address - Street 1:1530 BROAD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-3601
Practice Address - Country:US
Practice Address - Phone:228-865-1330
Practice Address - Fax:228-865-1331
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR725927363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00342756OtherRAILROAD MEDICARE
MS02858597Medicaid
Q71133Medicare UPIN
C02221Medicare PIN
MS02858597Medicaid