=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609557396
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WENDY WINSTON-BRISTER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2023
-----------------------------------------------------
Last Update Date | 05/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1910 LAKELAND DR STE B
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-5029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-260-0385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 APPLE BLOSSOM DR
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39047-7443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-260-0385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 906121
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------