Basic Information
| Provider Information | |||||||||
| NPI: | 1245655661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BREES | ||||||||
| FirstName: | CHARITY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | NNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAMBOLI | ||||||||
| OtherFirstName: | CHARITY | ||||||||
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| OtherCredential: | NNP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 504 CLINTON CENTER DRIVE | ||||||||
| Address2: | CBO-SUITE 4300 | ||||||||
| City: | CLINTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018152005 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4566 SOUTH EASON BLVD | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845261 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2014 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0000X | 854946 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
ID Information
| ID | Type | State | Issuer | Description | 01150068 | 05 | MS | MEDICAID |