Basic Information
Provider Information | |||||||||
NPI: | 1194017509 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROLAND | ||||||||
FirstName: | EDWINA | ||||||||
MiddleName: | INEZ | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JACKSON | ||||||||
OtherFirstName: | EDWINA | ||||||||
OtherMiddleName: | INEZ | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1175 OCEAN SPRINGS RD | ||||||||
Address2: |   | ||||||||
City: | OCEAN SPRINGS | ||||||||
State: | MS | ||||||||
PostalCode: | 395643421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2288722403 | ||||||||
FaxNumber: | 2288724027 | ||||||||
Practice Location | |||||||||
Address1: | 1175 OCEAN SPRINGS RD | ||||||||
Address2: |   | ||||||||
City: | OCEAN SPRINGS | ||||||||
State: | MS | ||||||||
PostalCode: | 395643421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2288722403 | ||||||||
FaxNumber: | 2288724027 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2011 | ||||||||
LastUpdateDate: | 09/16/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R872799 | MS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.