Healthcare Provider Details

I. General information

NPI: 1932566742
Provider Name (Legal Business Name): KWANZA AYANNA PRICE MSN, RN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 SEDGWICK DR
JACKSON MS
39211-3448
US

IV. Provider business mailing address

5820 SEDGWICK DR
JACKSON MS
39211-3448
US

V. Phone/Fax

Practice location:
  • Phone: 601-832-5261
  • Fax: 601-952-0191
Mailing address:
  • Phone: 601-832-5261
  • Fax: 601-952-0191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number892403
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number901675
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: