Healthcare Provider Details

I. General information

NPI: 1083071237
Provider Name (Legal Business Name): WANDA BROWN WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4240 BETHEL RD STE 101
OLIVE BRANCH MS
38654-8737
US

IV. Provider business mailing address

1211 UNION AVE STE 330
MEMPHIS TN
38104-6655
US

V. Phone/Fax

Practice location:
  • Phone: 662-932-9544
  • Fax: 662-932-9554
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number901414
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number901414
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: