Provider Demographics
NPI:1053554808
Name:RICHARDS, JULIET W
Entity type:Individual
Prefix:
First Name:JULIET
Middle Name:W
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15444 DEDEAUX RD STE B
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2637
Mailing Address - Country:US
Mailing Address - Phone:228-832-9038
Mailing Address - Fax:228-832-9990
Practice Address - Street 1:15444 DEDEAUX RD STE B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2637
Practice Address - Country:US
Practice Address - Phone:228-832-9038
Practice Address - Fax:228-832-9990
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA810304363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01859794Medicaid
MS432372YXF9OtherMEDICARE PTAN
MSR882326OtherSTATE LICENSE