Provider Demographics
NPI:1831440759
Name:PITTMAN, COURTNEY (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:
Last Name:PITTMAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:AVERETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:PO BOX 2106
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2106
Mailing Address - Country:US
Mailing Address - Phone:601-703-3018
Mailing Address - Fax:601-703-9283
Practice Address - Street 1:1500 HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-5335
Practice Address - Country:US
Practice Address - Phone:601-483-5353
Practice Address - Fax:601-482-1753
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR879673363L00000X
MS879673363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01487866Medicaid
LA2319116Medicaid
LA2319116Medicaid
259979YLC6Medicare PIN