MEDICARE: MR. STACY MAURICE BROWN FNP-BC

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	363LF0000X	Family Nurse Practitioner	902554	MS

General Provider Information

NPI Number	:	1720583784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STACY MAURICE BROWN FNP-BC

Provider Business Mailing Address
First Line	:	290 HIGHWAY 51 N
Second Line	:
City	:	BROOKHAVEN
State	:	MS
Zip	:	39601-2654
Country	:	US
Telephone Number	:	601-825-7280
Fax Number	:

Provider Business Practice Location Address
First Line	:	290 HIGHWAY 51 N
Second Line	:
City	:	BROOKHAVEN
State	:	MS
Zip	:	39601-2654
Country	:	US
Telephone Number	:	601-933-2500
Fax Number	:

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

Provider Enumeration Date	:	03/29/2018
Last Update Date	:	03/29/2018

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