Provider Demographics
NPI:1861963373
Name:MAYNE, GRACE ANN (WHNP)
Entity type:Individual
Prefix:
First Name:GRACE ANN
Middle Name:
Last Name:MAYNE
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 VICKLAN ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3954
Mailing Address - Country:US
Mailing Address - Phone:662-902-5236
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE ST STE 430
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2027
Practice Address - Country:US
Practice Address - Phone:601-487-7141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903061363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner