Healthcare Provider Details

I. General information

NPI: 1972422046
Provider Name (Legal Business Name): DARRIES ILLYSA LANGSTON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 321
BRANDON MS
39043-0321
US

IV. Provider business mailing address

PO BOX 321
BRANDON MS
39043-0321
US

V. Phone/Fax

Practice location:
  • Phone: 769-218-9082
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number905242
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: