Provider Demographics
NPI:1134163512
Name:COCKRELL, LINDA (NP)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:COCKRELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 FARMER ST
Mailing Address - Street 2:
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-2319
Mailing Address - Country:US
Mailing Address - Phone:601-437-3037
Mailing Address - Fax:601-437-4315
Practice Address - Street 1:703 FARMER ST
Practice Address - Street 2:
Practice Address - City:PORT GIBSON
Practice Address - State:MS
Practice Address - Zip Code:39150-2319
Practice Address - Country:US
Practice Address - Phone:601-437-3037
Practice Address - Fax:601-437-4315
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR747936363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04983840Medicaid
LA1034827Medicaid
MS202011213AOtherBLUE CROSS
MS04983840Medicaid
MS$$$$$$$$$BOtherBCBS
MS04983840Medicaid
MS202011213AOtherBLUE CROSS
MS512I500089Medicare PIN
MSQ22073Medicare UPIN