Healthcare Provider Details

I. General information

NPI: 1104860907
Provider Name (Legal Business Name): RONNIE KEITH BROWN NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 HIGHWAY 16 E
CARTHAGE MS
39051
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 315
MEMPHIS TN
38120-9401
US

V. Phone/Fax

Practice location:
  • Phone: 601-253-0173
  • Fax: 601-346-2352
Mailing address:
  • Phone:
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR805591
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: