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General NPI Number Information
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NPI Number | 1215622972
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Entity Type | Organization
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Legal Business Name | COMMUNITY WELLNESS GROUP LLC
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Dates
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Enumeration Date | 04/10/2023
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Last Update Date | 04/10/2023
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Provider Practice Location Address
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Address Line | 332 E MONTICELLO ST
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City | BROOKHAVEN
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State | MS
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Zip | 39601-3430
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Country | US
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Telephone | 601-669-7357
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Fax |
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Provider Business Mailing Address
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Address Line | 332 E MONTICELLO ST
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City | BROOKHAVEN
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State | MS
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Zip | 39601-3430
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Country | US
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Telephone | 601-669-7357
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | KIARA D MERCHANT
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Credential | FNP
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Telephone | 601-669-7357
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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 |
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License Number State |
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