Provider Demographics
NPI:1780729665
Name:GLEASON, SHERRY S
Entity type:Individual
Prefix:
First Name:SHERRY
Middle Name:S
Last Name:GLEASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHERRY
Other - Middle Name:
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:2510 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9513
Mailing Address - Country:US
Mailing Address - Phone:601-355-1234
Mailing Address - Fax:601-326-3559
Practice Address - Street 1:2510 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9513
Practice Address - Country:US
Practice Address - Phone:601-355-1234
Practice Address - Fax:601-326-3559
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR805937363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09370254Medicaid
MS302I504310Medicare PIN