Provider Demographics
NPI:1144695669
Name:SANDERS- SMITH, KERRIE
Entity type:Individual
Prefix:
First Name:KERRIE
Middle Name:
Last Name:SANDERS- SMITH
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 1:140 ALFRED DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-9102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4077 PEMBERTON SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5580
Practice Address - Country:US
Practice Address - Phone:601-638-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS875209363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily