MEDICARE: BETTYE BRINSON LOGAN FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	R623172	MS
2	363LF0000X	Family Nurse Practitioner	623172	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	7064459	OTHER	MS	AETNA
3	7923884	OTHER		CIGNA

General Provider Information

NPI Number	:	1376504597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETTYE BRINSON LOGAN FNP

Provider Business Mailing Address
First Line	:	415 S 28TH AVE
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39401-7246
Country	:	US
Telephone Number	:	601-765-4414
Fax Number	:	601-579-5240

Provider Business Practice Location Address
First Line	:	704 S 5TH ST
Second Line	:
City	:	COLLINS
State	:	MS
Zip	:	39428-4147
Country	:	US
Telephone Number	:	601-765-4414
Fax Number	:	601-765-9141

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	07/20/2020

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