Healthcare Provider Details

I. General information

NPI: 1316984149
Provider Name (Legal Business Name): ANDREA KOOSNE GARRISON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4577 S EASON BLVD
TUPELO MS
38801-6590
US

IV. Provider business mailing address

1937 BRIAR RIDGE RD
TUPELO MS
38804-5963
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-7590
  • Fax: 662-377-7595
Mailing address:
  • Phone: 662-690-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number17069
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: