Healthcare Provider Details

I. General information

NPI: 1891233276
Provider Name (Legal Business Name): OPTIMUM HEALTHCARE ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 11/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5350 EXECUTIVE PL SUITE 8
JACKSON MS
39206-4100
US

IV. Provider business mailing address

PO BOX 1906
MADISON MS
39130-1906
US

V. Phone/Fax

Practice location:
  • Phone: 601-927-1872
  • Fax: 949-607-3442
Mailing address:
  • Phone: 601-942-8447
  • Fax: 949-607-3442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR784445
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR784445
License Number StateMS

VIII. Authorized Official

Name: DR. FELISA DENISE WILSON-SIMPSON
Title or Position: OWNER/CEO/NP
Credential: PHD, FNP-BC, PNP-BC
Phone: 601-397-6236