Provider Demographics
NPI:1730793688
Name:GADDIS, SHARON
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:GADDIS
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 1:3825 MOUNT CHARITY RD
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MS
Mailing Address - Zip Code:39051-8666
Mailing Address - Country:US
Mailing Address - Phone:601-750-0737
Mailing Address - Fax:
Practice Address - Street 1:3825 MOUNT CHARITY RD
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MS
Practice Address - Zip Code:39051-8666
Practice Address - Country:US
Practice Address - Phone:601-750-0737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS802102760172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver