Provider Demographics
NPI:1639746001
Name:SMITH, BRANDON COBY (AANP, FNP-C, ENP-C)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:COBY
Last Name:SMITH
Suffix:
Gender:M
Credentials:AANP, FNP-C, ENP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 E SYCAMORE
Mailing Address - Street 2:
Mailing Address - City:SUMRALL
Mailing Address - State:MS
Mailing Address - Zip Code:39482-5503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 E SYCAMORE
Practice Address - Street 2:
Practice Address - City:SUMRALL
Practice Address - State:MS
Practice Address - Zip Code:39482-5503
Practice Address - Country:US
Practice Address - Phone:662-310-3788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-05
Last Update Date:2021-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904560363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily