Provider Demographics
NPI:1306105705
Name:PHILLIPS, BRENDA LEE (DNP PMHNP-BC, FNP-BC)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:LEE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:DNP PMHNP-BC, FNP-BC
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 4128
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39304-4128
Mailing Address - Country:US
Mailing Address - Phone:601-581-8526
Mailing Address - Fax:
Practice Address - Street 1:1451 N LAKELAND DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-9020
Practice Address - Country:US
Practice Address - Phone:601-581-8526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR852932363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08689796Medicaid
MS302I506451Medicare PIN