Healthcare Provider Details

I. General information

NPI: 1790864635
Provider Name (Legal Business Name): BEVERLY C. BUCHANAN RN, PHD, CWCN-APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 02/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E WOODROW WILSON AVE
JACKSON MS
39216-5116
US

IV. Provider business mailing address

1175 PINE ACRES RD
TERRY MS
39170-7627
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-4471
  • Fax: 601-364-1305
Mailing address:
  • Phone: 601-878-6908
  • Fax: 601-878-2400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License NumberR523623
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code163WE0900X
TaxonomyEnterostomal Therapy Registered Nurse
License NumberR523623
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberR523623/#2002148630
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: