Healthcare Provider Details

I. General information

NPI: 1780367128
Provider Name (Legal Business Name): BRITT THE NP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2023
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 S 42ND ST
MOUNT VERNON IL
62864-6216
US

IV. Provider business mailing address

16915 N CASEY PIKE LN
MOUNT VERNON IL
62864-7513
US

V. Phone/Fax

Practice location:
  • Phone: 618-472-6650
  • Fax:
Mailing address:
  • Phone: 618-472-6650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRITTNI ROLDAN
Title or Position: PMHNP
Credential: NURSE PRACTITIONER
Phone: 618-472-6650