| Organization Name: | OLD TOWNE MEDICAL LLC |
| NPI Number: | 1013312172 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | SUSAN C BRAME (OWNER) |
| Mailing Address: | 9066 Highland St Olive Branch |
| State: | MS US |
| Postal Code: | 386542307 |
| Phone Number: | 6628746164 |
| Fax Number: | |
| NPI Enumeration Date: | 10/30/2014 |
| NPI Last Update Date: | 10/22/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | R644986 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MS |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |