Provider Demographics
NPI:1912321175
Name:LORDEON, GWENDOLYN SPRAYBERRY (MSN, NP-C)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:SPRAYBERRY
Last Name:LORDEON
Suffix:
Gender:F
Credentials:MSN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 COUNTY ROAD 380
Mailing Address - Street 2:
Mailing Address - City:CALHOUN CITY
Mailing Address - State:MS
Mailing Address - Zip Code:38916-7111
Mailing Address - Country:US
Mailing Address - Phone:662-414-6271
Mailing Address - Fax:662-227-2296
Practice Address - Street 1:340 VAN DORN ST
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4738
Practice Address - Country:US
Practice Address - Phone:662-226-0325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-09
Last Update Date:2014-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR765701363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily