Provider Demographics
NPI:1336789387
Name:BRILEY, MICHELLE GARDNER (FNP-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GARDNER
Last Name:BRILEY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MS
Mailing Address - Zip Code:38843-8862
Mailing Address - Country:US
Mailing Address - Phone:662-862-4422
Mailing Address - Fax:
Practice Address - Street 1:341 E MAIN ST STE A1
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-4040
Practice Address - Country:US
Practice Address - Phone:662-807-4232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF12190851363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily