Provider Demographics
NPI:1073105334
Name:BRANCH OF LOVE
Entity Type:Organization
Organization Name:BRANCH OF LOVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:LADONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, AGNP-C, PMHNP-B
Authorized Official - Phone:601-498-8132
Mailing Address - Street 1:22 SHIRLEY DR
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-5149
Mailing Address - Country:US
Mailing Address - Phone:601-498-8132
Mailing Address - Fax:
Practice Address - Street 1:22 SHIRLEY DR
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-5149
Practice Address - Country:US
Practice Address - Phone:601-498-8132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care