Healthcare Provider Details

I. General information

NPI: 1952949182
Provider Name (Legal Business Name): BRANDY CARR WILSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1167 E BROAD ST
MONTICELLO MS
39654-7682
US

IV. Provider business mailing address

PO BOX 1884
MONTICELLO MS
39654-1884
US

V. Phone/Fax

Practice location:
  • Phone: 601-587-1433
  • Fax: 601-587-1625
Mailing address:
  • Phone: 601-695-2524
  • Fax: 601-587-1625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number903719
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: