Basic Information
| Provider Information | |||||||||
| NPI: | 1720497951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BREWER | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | BOYLES | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 9012278591 | ||||||||
| Practice Location | |||||||||
| Address1: | 971 LAKELAND DR STE 1250 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013661011 | ||||||||
| FaxNumber: | 6013667311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2014 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R882776 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.