Provider Demographics
NPI:1114403268
Name:GINN, KATHERINE PUCKETT (NP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:PUCKETT
Last Name:GINN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 RIVER OAKS DR STE 302
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9575
Mailing Address - Country:US
Mailing Address - Phone:601-939-9923
Mailing Address - Fax:601-939-9924
Practice Address - Street 1:1040 RIVER OAKS DR STE 302
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9575
Practice Address - Country:US
Practice Address - Phone:601-939-9923
Practice Address - Fax:601-939-9924
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902808363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08220070Medicaid
MSP02359034OtherRAILROAD MEDICARE
MS688710OtherMEDICARE