Provider Demographics
NPI:1629135751
Name:HORTON, BRENDA (L P N)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:HORTON
Suffix:
Gender:F
Credentials:L P N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 COUNTY ROAD 3501
Mailing Address - Street 2:
Mailing Address - City:NEW SITE
Mailing Address - State:MS
Mailing Address - Zip Code:38859-9579
Mailing Address - Country:US
Mailing Address - Phone:662-728-5427
Mailing Address - Fax:
Practice Address - Street 1:390 COUNTY ROAD 3501
Practice Address - Street 2:
Practice Address - City:NEW SITE
Practice Address - State:MS
Practice Address - Zip Code:38859-9579
Practice Address - Country:US
Practice Address - Phone:662-728-5427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP205656164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770279Medicaid