Provider Demographics
NPI:1861898355
Name:NORMAN, DESIREE (NP)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:NORMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:11150 HIGHWAY 49
Mailing Address - Street 2:MBH OUTPATIENT CLINIC
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4110
Mailing Address - Country:US
Mailing Address - Phone:228-575-1000
Mailing Address - Fax:228-575-2002
Practice Address - Street 1:11150 HIGHWAY 49
Practice Address - Street 2:MBH OUTPATIENT CLINIC
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4110
Practice Address - Country:US
Practice Address - Phone:228-575-1000
Practice Address - Fax:228-575-2002
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872705363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01858357Medicaid