Provider Demographics
NPI:1194209064
Name:BOLTON, BRANDI (FNP)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:BOLTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-3572
Mailing Address - Country:US
Mailing Address - Phone:205-233-3043
Mailing Address - Fax:
Practice Address - Street 1:1806 SIMPSON HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-5391
Practice Address - Country:US
Practice Address - Phone:601-439-1420
Practice Address - Fax:601-439-1421
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-145196363LA2100X
MS902911363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care