Healthcare Provider Details

I. General information

NPI: 1568930469
Provider Name (Legal Business Name): BATHSHEBA BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 BROOKMAN DR EXT
BROOKHAVEN MS
39601-2340
US

IV. Provider business mailing address

13022 MONTICELLO RD
HAZLEHURST MS
39083-9108
US

V. Phone/Fax

Practice location:
  • Phone: 601-823-5700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number856497
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: