Provider Demographics
NPI:1386721652
Name:VANNORMAN, KETURAH MICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:KETURAH
Middle Name:MICHELLE
Last Name:VANNORMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 CROSSGATE DR W
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2233
Mailing Address - Country:US
Mailing Address - Phone:601-825-0925
Mailing Address - Fax:601-825-0967
Practice Address - Street 1:1405 CROSSGATE DR W
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2233
Practice Address - Country:US
Practice Address - Phone:601-825-0925
Practice Address - Fax:601-825-0967
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15788208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics