Provider Demographics
NPI:1366108805
Name:PREMIER HEALTH & WELLNESS CLINIC
Entity type:Organization
Organization Name:PREMIER HEALTH & WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAVEN
Authorized Official - Middle Name:MISHAEL
Authorized Official - Last Name:CAMPBELL-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:601-304-2421
Mailing Address - Street 1:300 HIGHLAND BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4600
Mailing Address - Country:US
Mailing Address - Phone:601-304-2421
Mailing Address - Fax:601-446-6428
Practice Address - Street 1:300 HIGHLAND BLVD STE B
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4600
Practice Address - Country:US
Practice Address - Phone:601-304-2421
Practice Address - Fax:601-446-6428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-09
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty