Healthcare Provider Details

I. General information

NPI: 1265809685
Provider Name (Legal Business Name): BRYCE DOUGLAS KINCAID FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR
JACKSON MS
39216-4606
US

IV. Provider business mailing address

305 WHITE OAK DR
BRANDON MS
39047-6803
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-4644
  • Fax: 601-200-4645
Mailing address:
  • Phone: 601-200-4749
  • Fax: 601-200-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR874696
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: