Provider Demographics
NPI:1205896842
Name:GADDIS, LORRAINE (CFNP)
Entity type:Individual
Prefix:MS
First Name:LORRAINE
Middle Name:
Last Name:GADDIS
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:MRS
Other - First Name:LORRAINE
Other - Middle Name:
Other - Last Name:HAMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4749
Mailing Address - Fax:601-200-5929
Practice Address - Street 1:127 GRANDVIEW DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7595
Practice Address - Country:US
Practice Address - Phone:601-853-0203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALR741224363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03282005Medicaid
MS500001878Medicare ID - Type Unspecified
MSQ46523Medicare UPIN