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General NPI Number Information
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NPI Number | 1013312172
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Entity Type | Organization
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Legal Business Name | OLD TOWNE MEDICAL LLC
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Dates
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Enumeration Date | 10/30/2014
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Last Update Date | 07/30/2019
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Provider Practice Location Address
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Address Line | 9066 HIGHLAND ST
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-2307
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Country | US
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Telephone | 662-890-7717
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Fax | 662-874-6038
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Provider Business Mailing Address
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Address Line | 9066 HIGHLAND ST
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-2307
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Country | US
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Telephone | 662-890-7717
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Fax | 662-874-6038
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Authorized Official
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Title or Position | OWNER
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Name | SUSAN C BRAME
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Credential | CFNP
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Telephone | 901-489-6595
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | R644986
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License Number State | MS
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