Healthcare Provider Details

I. General information

NPI: 1831329887
Provider Name (Legal Business Name): CHARLESTON CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S CHURCH ST
CHARLESTON MS
38921-2257
US

IV. Provider business mailing address

P. O. BOX 21
CHARLESTON MS
38921
US

V. Phone/Fax

Practice location:
  • Phone: 662-647-5816
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License NumberR865030
License Number StateMS

VIII. Authorized Official

Name: MRS. LISA SUDDUTH BRADHAM
Title or Position: NURSE PRACTITIONER
Credential: FNP
Phone: 662-647-5816