Provider Demographics
NPI:1568572055
Name:SMOOT, BRENDA L (FNP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:L
Last Name:SMOOT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:BRENDA
Other - Middle Name:L
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:4150 S SIWELL RD
Mailing Address - Street 2:NONE
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-6209
Mailing Address - Country:US
Mailing Address - Phone:601-362-4471
Mailing Address - Fax:601-364-1357
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:NONE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:601-364-1357
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR856673363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily