Provider Demographics
NPI:1275321754
Name:BROOKHAVEN DIABETES AND PRIMARY CARE CLINIC
Entity type:Organization
Organization Name:BROOKHAVEN DIABETES AND PRIMARY CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CASE
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP, BC-ADM, CDCES
Authorized Official - Phone:601-320-1246
Mailing Address - Street 1:317 JAKES TRL NW
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-8632
Mailing Address - Country:US
Mailing Address - Phone:601-320-1246
Mailing Address - Fax:
Practice Address - Street 1:317 JAKES TRL NW
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-8632
Practice Address - Country:US
Practice Address - Phone:601-320-1246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-25
Last Update Date:2025-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty