Healthcare Provider Details

I. General information

NPI: 1659336196
Provider Name (Legal Business Name): SUSAN C BRAME FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9066 HIGHLAND ST
OLIVE BRANCH MS
38654-2307
US

IV. Provider business mailing address

9066 HIGHLAND ST
OLIVE BRANCH MS
38654-2307
US

V. Phone/Fax

Practice location:
  • Phone: 662-890-7717
  • Fax: 662-874-6038
Mailing address:
  • Phone: 662-890-7717
  • Fax: 662-874-6038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR644986
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR644986
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: