Provider Demographics
NPI:1710472790
Name:YELVERTON, ALLEN BRELAND
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:BRELAND
Last Name:YELVERTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 HIGHWAY 61 N
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-8246
Mailing Address - Country:US
Mailing Address - Phone:601-883-3391
Mailing Address - Fax:
Practice Address - Street 1:3317 PEMBERTON SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5578
Practice Address - Country:US
Practice Address - Phone:601-636-1173
Practice Address - Fax:601-638-8287
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902697363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner