Provider Demographics
NPI:1659336196
Name:BRAME, SUSAN C (FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:BRAME
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
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Mailing Address - Street 1:9066 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-2307
Mailing Address - Country:US
Mailing Address - Phone:662-890-7717
Mailing Address - Fax:662-874-6038
Practice Address - Street 1:9066 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-2307
Practice Address - Country:US
Practice Address - Phone:662-890-7717
Practice Address - Fax:662-874-6038
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSR644986207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121759Medicaid
MS00121759Medicaid
MSMB0951562OtherDEA LIC
MS00121759Medicaid