Healthcare Provider Details

I. General information

NPI: 1982247888
Provider Name (Legal Business Name): OLIVIA CARSYN BURCH FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1529 SIMPSON HIGHWAY 49 STE A
MAGEE MS
39111-4209
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-439-7288
  • Fax:
Mailing address:
  • Phone: 601-849-1530
  • Fax: 601-849-1535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number903579
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: