Basic Information
| Provider Information | |||||||||
| NPI: | 1831440759 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PITTMAN | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AVERETT | ||||||||
| OtherFirstName: | COURTNEY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-BC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2106 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393022106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017033018 | ||||||||
| FaxNumber: | 6017039283 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 HIGHWAY 19 N | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393075335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014835353 | ||||||||
| FaxNumber: | 6014821753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2012 | ||||||||
| LastUpdateDate: | 10/05/2018 | ||||||||
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| 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 | 363L00000X | R879673 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 879673 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 01487866 | 05 | MS | MEDICAID | 2319116 | 05 | LA | MEDICAID |