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Organization
CHARLESTON CLINIC
Active
Organization
CHARLESTON CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. LISA SUDDUTH BRADHAM FNP (NURSE PRACTITIONER)
(662) 647-5816
Entity
Organization
Contact information
Practice address
401 S CHURCH ST, CHARLESTON, MS 38921-2257
(662) 647-5816
Mailing address
P. O. BOX 21, CHARLESTON, MS 38921
Taxonomy
Speciality
Code
Description
License number
State
363LC1500X
Community Health Nurse Practitioner
Primary
R865030
MS
Other
Enumeration date
07/23/2009
Last updated
07/06/2011
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