Healthcare Provider Details

I. General information

NPI: 1144548744
Provider Name (Legal Business Name): BRENT FONDSHAY BROOME CNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2010
Last Update Date: 10/27/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 DAVID PATTERSON RD
MOSELLE MS
39459
US

IV. Provider business mailing address

6 DAVID PATTERSON RD
MOSELLE MS
39459-9439
US

V. Phone/Fax

Practice location:
  • Phone: 601-596-3786
  • Fax:
Mailing address:
  • Phone: 601-596-3786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberA034616
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberA034616
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: