Healthcare Provider Details

I. General information

NPI: 1225516354
Provider Name (Legal Business Name): WHITEHEAD WOUND CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 HIGHWAY 51 N
BROOKHAVEN MS
39601-2350
US

IV. Provider business mailing address

PO BOX 756
CENTREVILLE MS
39631-0756
US

V. Phone/Fax

Practice location:
  • Phone: 601-835-9444
  • Fax:
Mailing address:
  • Phone: 601-395-2585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR853722
License Number StateMS

VIII. Authorized Official

Name: MRS. LESA COLLEEN WHITEHEAD
Title or Position: NP-C
Credential: NP-C
Phone: 601-395-2585