Provider Demographics
NPI:1316963911
Name:CORDLE, MARY-ELIZABETH (NP)
Entity type:Individual
Prefix:
First Name:MARY-ELIZABETH
Middle Name:
Last Name:CORDLE
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 1:4509 GIBSON ROAD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564
Mailing Address - Country:US
Mailing Address - Phone:228-892-3993
Mailing Address - Fax:228-872-3992
Practice Address - Street 1:4509 GIBSON ROAD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564
Practice Address - Country:US
Practice Address - Phone:228-892-3993
Practice Address - Fax:228-872-3992
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS894998363LA2100X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALQ08870Medicare UPIN
AL515-54615Medicare ID - Type Unspecified