Basic Information
| Provider Information | |||||||||
| NPI: | 1366108805 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER HEALTH & WELLNESS CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 HIGHLAND BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | NATCHEZ | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391204600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013042421 | ||||||||
| FaxNumber: | 6014466428 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 HIGHLAND BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | NATCHEZ | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391204600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013042421 | ||||||||
| FaxNumber: | 6014466428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2021 | ||||||||
| LastUpdateDate: | 03/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | CAMPBELL-SMITH | ||||||||
| AuthorizedOfficialFirstName: | RAVEN | ||||||||
| AuthorizedOfficialMiddleName: | MISHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6013042421 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | FNP-C | ||||||||
| NPICertificationDate: | 03/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.