Healthcare Provider Details

I. General information

NPI: 1376504597
Provider Name (Legal Business Name): BETTYE BRINSON LOGAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 S 5TH ST
COLLINS MS
39428-4147
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-765-4414
  • Fax: 601-765-9141
Mailing address:
  • Phone: 601-765-4414
  • Fax: 601-579-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR623172
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number623172
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: