Healthcare Provider Details

I. General information

NPI: 1992549463
Provider Name (Legal Business Name): BRANDI FENNELL SMITH FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 06/20/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 HARDY ST
HATTIESBURG MS
39402-1308
US

IV. Provider business mailing address

14 E SPRUCE
SUMRALL MS
39482-5476
US

V. Phone/Fax

Practice location:
  • Phone: 601-268-8000
  • Fax:
Mailing address:
  • Phone: 256-740-2632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number906743
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: