Provider Demographics
NPI:1891233276
Name:OPTIMUM HEALTHCARE ASSOCIATES, PA
Entity Type:Organization
Organization Name:OPTIMUM HEALTHCARE ASSOCIATES, PA
Other - Org Name:OPTIMUM HEALTHCARE ASSOCIATES, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/CEO/NP
Authorized Official - Prefix:DR
Authorized Official - First Name:FELISA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:WILSON-SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, FNP-BC, PNP-BC
Authorized Official - Phone:601-397-6236
Mailing Address - Street 1:PO BOX 1906
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-1906
Mailing Address - Country:US
Mailing Address - Phone:601-942-8447
Mailing Address - Fax:949-607-3442
Practice Address - Street 1:5350 EXECUTIVE PL
Practice Address - Street 2:SUITE 8
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-4100
Practice Address - Country:US
Practice Address - Phone:601-927-1872
Practice Address - Fax:949-607-3442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-06
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR784445363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty