Healthcare Provider Details

I. General information

NPI: 1174870802
Provider Name (Legal Business Name): MRS. ELIZABETH BROOKE WILBANKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 11/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 E SHILOH RD
CORINTH MS
38834-3724
US

IV. Provider business mailing address

868 COUNTY ROAD 518
RIENZI MS
38865-9001
US

V. Phone/Fax

Practice location:
  • Phone: 662-287-6999
  • Fax:
Mailing address:
  • Phone: 662-603-1117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR874715
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: