Provider Demographics
NPI:1538208830
Name:COOLEY, JULIE GRISSOM (NP)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:GRISSOM
Last Name:COOLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:GRISSOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-5010
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-579-5010
Practice Address - Fax:601-579-5240
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS859459363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS753068151OtherMHP
753068151017OtherTRICARE
MSP00274670OtherMEDICARE RR
MS06782894Medicaid
MS06782894Medicaid
MSQ29681Medicare UPIN
MS06782894Medicaid
MS753068151OtherMHP