Healthcare Provider Details

I. General information

NPI: 1427556828
Provider Name (Legal Business Name): CAMILLE WHITEHEAD FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 HIGHWAY 72
BURNSVILLE MS
38833-9320
US

IV. Provider business mailing address

PO BOX 214
BURNSVILLE MS
38833-0214
US

V. Phone/Fax

Practice location:
  • Phone: 662-427-4040
  • Fax: 662-427-4041
Mailing address:
  • Phone: 662-427-4040
  • Fax: 662-427-4041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902481
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: