Healthcare Provider Details

I. General information

NPI: 1497762256
Provider Name (Legal Business Name): GRETA LOUISE KEYS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. GRETA L WILLIAMS

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 E MONTICELLO ST
BROOKHAVEN MS
39601-3430
US

IV. Provider business mailing address

332 E MONTICELLO ST
BROOKHAVEN MS
39601-3430
US

V. Phone/Fax

Practice location:
  • Phone: 601-833-3500
  • Fax: 601-292-6384
Mailing address:
  • Phone: 601-833-3500
  • Fax: 601-292-6384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR843927
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: