Healthcare Provider Details

I. General information

NPI: 1083203871
Provider Name (Legal Business Name): SUSAN BRINSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2832 SMITH ROBINSON ST
JACKSON MS
39213-6645
US

IV. Provider business mailing address

PO BOX 3133
JACKSON MS
39207-3133
US

V. Phone/Fax

Practice location:
  • Phone: 601-672-2947
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberR862538
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: