Provider Demographics
NPI:1891855623
Name:HERNDON, GWENDOLYN K (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:K
Last Name:HERNDON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-2163
Mailing Address - Country:US
Mailing Address - Phone:662-615-2503
Mailing Address - Fax:662-615-2554
Practice Address - Street 1:400 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2163
Practice Address - Country:US
Practice Address - Phone:662-615-2503
Practice Address - Fax:662-615-2554
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR643653363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00112980Medicaid
MS00112980Medicaid
MS500002016Medicare PIN