Healthcare Provider Details

I. General information

NPI: 1972332864
Provider Name (Legal Business Name): ELIZABETH GRACE BRASWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CAPITOL ST
CLINTON MS
39056-4026
US

IV. Provider business mailing address

200 CAPITOL ST
CLINTON MS
39056-4026
US

V. Phone/Fax

Practice location:
  • Phone: 601-925-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00875
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: