Basic Information
Provider Information | |||||||||
NPI: | 1538208830 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COOLEY | ||||||||
FirstName: | JULIE | ||||||||
MiddleName: | GRISSOM | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRISSOM | ||||||||
OtherFirstName: | JULIE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 415 S 28TH AVE | ||||||||
Address2: |   | ||||||||
City: | HATTIESBURG | ||||||||
State: | MS | ||||||||
PostalCode: | 394017246 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6015795010 | ||||||||
FaxNumber: | 6015795240 | ||||||||
Practice Location | |||||||||
Address1: | 415 S 28TH AVE | ||||||||
Address2: |   | ||||||||
City: | HATTIESBURG | ||||||||
State: | MS | ||||||||
PostalCode: | 394017246 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6015795010 | ||||||||
FaxNumber: | 6015795240 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2007 | ||||||||
LastUpdateDate: | 09/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 859459 | MS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 753068151 | 01 | MS | MHP | OTHER | 753068151017 | 01 |   | TRICARE | OTHER | P00274670 | 01 | MS | MEDICARE RR | OTHER | 06782894 | 05 | MS |   | MEDICAID |