Healthcare Provider Details

I. General information

NPI: 1497271415
Provider Name (Legal Business Name): BRANDI DAVIS JOHNSTON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 NORTH STATE STREET SUITE 420
JACKSON MS
39202
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 103
MEMPHIS TN
38120-9446
US

V. Phone/Fax

Practice location:
  • Phone: 601-355-3353
  • Fax:
Mailing address:
  • Phone: 901-227-3255
  • Fax: 901-227-3205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number902163
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number902163
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number902163
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: