Healthcare Provider Details

I. General information

NPI: 1265870018
Provider Name (Legal Business Name): LELA BRIANNE KATTAWAR FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7615 CLARINGTON CV
SOUTHAVEN MS
38671-5647
US

IV. Provider business mailing address

7615 CLARINGTON CV
SOUTHAVEN MS
38671-5647
US

V. Phone/Fax

Practice location:
  • Phone: 662-536-2500
  • Fax:
Mailing address:
  • Phone: 662-536-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR868653
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: