Provider Demographics
NPI:1831802669
Name:GATLIN, SHUWANDA NICOLE
Entity type:Individual
Prefix:
First Name:SHUWANDA
Middle Name:NICOLE
Last Name:GATLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 511
Mailing Address - Street 2:
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-0511
Mailing Address - Country:US
Mailing Address - Phone:601-876-8779
Mailing Address - Fax:
Practice Address - Street 1:69 GINNTOWN RD
Practice Address - Street 2:
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667-5597
Practice Address - Country:US
Practice Address - Phone:601-876-8779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS920882044Medicaid