Basic Information
| Provider Information | |||||||||
| NPI: | 1639522196 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCLEOD | ||||||||
| FirstName: | GENNITHA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON RICE | ||||||||
| OtherFirstName: | GENNITHA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 30 HOLMES DRIVE | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564033534 | ||||||||
| FaxNumber: | 2564033541 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HOLMES DRIVE | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564033534 | ||||||||
| FaxNumber: | 2564033541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2016 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN237968 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 003178587A | 05 | GA | MEDICAID | 202503I184 | 01 | GA | MEDICARE PTAN | OTHER |