Basic Information
| Provider Information | |||||||||
| NPI: | 1649463050 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREGG | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2510 LAKELAND DR | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013551234 | ||||||||
| FaxNumber: | 6013263559 | ||||||||
| Practice Location | |||||||||
| Address1: | 2510 LAKELAND DR | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013551234 | ||||||||
| FaxNumber: | 6013263559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2007 | ||||||||
| LastUpdateDate: | 06/18/2016 | ||||||||
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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 | 363LF0000X | R852809 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 01272323 | 05 | MS | MEDICAID |