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General NPI Number Information
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NPI Number | 1932742988
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Entity Type | Organization
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Legal Business Name | PURE LIGHT PSYCHIATRY LLC
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Dates
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Enumeration Date | 10/22/2019
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Last Update Date | 06/23/2025
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Provider Practice Location Address
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Address Line | 5600 GOODMAN RD STE B
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-7002
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Country | US
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Telephone | 662-890-7010
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Fax | 662-890-7044
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Provider Business Mailing Address
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Address Line | 5600 GOODMAN RD STE B
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-7002
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Country | US
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Telephone | 662-890-7010
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Fax | 662-890-7044
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Authorized Official
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Title or Position | PMHNP
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Name | MRS. STEPHANIE MACHELLE DOUGLASS
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Credential | APRN, PMHNP
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Telephone | 662-890-7010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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