Provider Demographics
NPI:1942089917
Name:BROOM, RIKKI SUZANNE (PNP)
Entity Type:Individual
Prefix:
First Name:RIKKI
Middle Name:SUZANNE
Last Name:BROOM
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 566
Mailing Address - Street 2:
Mailing Address - City:SUMRALL
Mailing Address - State:MS
Mailing Address - Zip Code:39482-0566
Mailing Address - Country:US
Mailing Address - Phone:601-336-9099
Mailing Address - Fax:
Practice Address - Street 1:4881 HWY 589
Practice Address - Street 2:
Practice Address - City:SUMRALL
Practice Address - State:MS
Practice Address - Zip Code:39482-3948
Practice Address - Country:US
Practice Address - Phone:601-336-9099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906303363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner