Healthcare Provider Details

I. General information

NPI: 1871521179
Provider Name (Legal Business Name): ANITA DENISE WREN CNNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-7100
  • Fax:
Mailing address:
  • Phone: 601-815-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberR687111
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: