Provider Demographics
NPI:1588984744
Name:GORETH, MICHELLE BORZIK (CPNP-AC)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:BORZIK
Last Name:GORETH
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:MRS
Other - First Name:DIANNA MICHELLE
Other - Middle Name:BORZIK
Other - Last Name:GORETH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CPNP-AC
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5050
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860018163WP0200X, 363LA2100X
TX794000363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL179192Medicaid
MS02855367Medicaid
MS314812YJ5DMedicare PIN