Basic Information
| Provider Information | |||||||||
| NPI: | 1508470121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOOKER | ||||||||
| FirstName: | HANNAH | ||||||||
| MiddleName: | OLIVIA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3407 SHAMROCK CT | ||||||||
| Address2: | |||||||||
| City: | GAUTIER | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395535337 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4905 TELEPHONE RD | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395671823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2287691280 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2020 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 00018214 | 05 | MS | MEDICAID |