Provider Demographics
NPI:1861911372
Name:WILLIAMS, BRENNAN (CPNP-DUAL)
Entity type:Individual
Prefix:MR
First Name:BRENNAN
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:CPNP-DUAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-8151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-15
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902321363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care