Healthcare Provider Details

I. General information

NPI: 1780125302
Provider Name (Legal Business Name): DEBRA BROWN WILLIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 BELLE OAK DR
BRANDON MS
39042-8251
US

IV. Provider business mailing address

216 BELLE OAK DR
BRANDON MS
39042-8251
US

V. Phone/Fax

Practice location:
  • Phone: 601-209-8037
  • Fax:
Mailing address:
  • Phone: 601-209-8037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2017003142
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number2017003142
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2017003142
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP133899
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: