Healthcare Provider Details

I. General information

NPI: 1073091963
Provider Name (Legal Business Name): BRANDON GARY ALLEN FNP-C, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402A LONG CREEK RD
MERIDIAN MS
39301-7594
US

IV. Provider business mailing address

2402A LONG CREEK RD
MERIDIAN MS
39301-7594
US

V. Phone/Fax

Practice location:
  • Phone: 601-490-9410
  • Fax: 855-852-1209
Mailing address:
  • Phone: 601-490-9410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number876372
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902766
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number902766
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: