Provider Demographics
NPI:1245014042
Name:MACK, GERRI (FNP-C)
Entity type:Individual
Prefix:MISS
First Name:GERRI
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-4625
Mailing Address - Country:US
Mailing Address - Phone:228-678-7036
Mailing Address - Fax:228-678-7038
Practice Address - Street 1:110 E RAILROAD ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-4625
Practice Address - Country:US
Practice Address - Phone:228-678-7036
Practice Address - Fax:228-678-7038
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA229709363LF0000X
MS905829363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA229709OtherAPRN
MS905829OtherMSBON