Healthcare Provider Details

I. General information

NPI: 1437872041
Provider Name (Legal Business Name): CHARLIE CRAFTON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 S HOLLY AVE
COLLINS MS
39428-3894
US

IV. Provider business mailing address

701 S HOLLY AVE
COLLINS MS
39428-3894
US

V. Phone/Fax

Practice location:
  • Phone: 601-765-6711
  • Fax:
Mailing address:
  • Phone: 601-765-6711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number905959
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: