Healthcare Provider Details

I. General information

NPI: 1023503554
Provider Name (Legal Business Name): GRENISHA L YOUNG APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 03/08/2022
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2941 TERRY RD STE 6
JACKSON MS
39212-3071
US

IV. Provider business mailing address

322 GREENSBORO DR
BRANDON MS
39047-4700
US

V. Phone/Fax

Practice location:
  • Phone: 601-363-0566
  • Fax:
Mailing address:
  • Phone: 601-334-0113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902641
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: