Healthcare Provider Details

I. General information

NPI: 1902661598
Provider Name (Legal Business Name): CHARLIE BROOKE HUTSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 JEFFERSON AVE
MEMPHIS TN
38103-2807
US

IV. Provider business mailing address

321 CRIMSONWOOD DR
BYHALIA MS
38611-7094
US

V. Phone/Fax

Practice location:
  • Phone: 901-545-7100
  • Fax: 901-448-8472
Mailing address:
  • Phone: 901-431-9297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5860
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: