Provider Demographics
NPI:1902448301
Name:GHOLSTON, CARRIE MCGREW
Entity Type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:MCGREW
Last Name:GHOLSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:ELIZABETH
Other - Last Name:MCGREW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:118 PALIN DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6962
Mailing Address - Country:US
Mailing Address - Phone:601-720-9991
Mailing Address - Fax:
Practice Address - Street 1:141 TOWNSHIP AVE STE 107
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-8697
Practice Address - Country:US
Practice Address - Phone:601-707-5676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-17
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903621363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health