Basic Information
| Provider Information | |||||||||
| NPI: | 1558636282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STURDIVANT | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | GORE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018156000 | ||||||||
| FaxNumber: | 6019845085 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018156000 | ||||||||
| FaxNumber: | 6019845085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2012 | ||||||||
| LastUpdateDate: | 03/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | A3608 | MS | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 07203769 | 05 | MS | MEDICAID | P01266932 | 01 | MS | RAILROAD MEDICARE | OTHER |