Healthcare Provider Details

I. General information

NPI: 1134555790
Provider Name (Legal Business Name): RENATA WEATHERSPOON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2013
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 KATHERINE DR STE A
FLOWOOD MS
39232-9588
US

IV. Provider business mailing address

6008 CAMERON BLVD
NEW ORLEANS LA
70122-4108
US

V. Phone/Fax

Practice location:
  • Phone: 601-665-4162
  • Fax: 888-398-1151
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number12.015744
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP126296
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP07557
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: