Provider Demographics
NPI:1316419245
Name:CREER, IMARI JERRELL
Entity type:Individual
Prefix:
First Name:IMARI
Middle Name:JERRELL
Last Name:CREER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IMARI
Other - Middle Name:JERRELL
Other - Last Name:MCGHEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4594
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-4594
Mailing Address - Country:US
Mailing Address - Phone:228-273-4096
Mailing Address - Fax:228-594-1765
Practice Address - Street 1:180B DEBUYS RD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4404
Practice Address - Country:US
Practice Address - Phone:228-273-4096
Practice Address - Fax:228-594-1765
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903018363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08433394Medicaid