Provider Demographics
NPI:1831329887
Name:CHARLESTON CLINIC
Entity type:Organization
Organization Name:CHARLESTON CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:SUDDUTH
Authorized Official - Last Name:BRADHAM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-647-5816
Mailing Address - Street 1:P. O. BOX 21
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:MS
Mailing Address - Zip Code:38921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:MS
Practice Address - Zip Code:38921-2257
Practice Address - Country:US
Practice Address - Phone:662-647-5816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-23
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865030363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Single Specialty