Healthcare Provider Details

I. General information

NPI: 1023680287
Provider Name (Legal Business Name): MELANIE SPENCER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 HENRY CANNON RD
BRAXTON MS
39044-9656
US

IV. Provider business mailing address

458 HENRY CANNON RD
BRAXTON MS
39044-9656
US

V. Phone/Fax

Practice location:
  • Phone: 601-572-5518
  • Fax:
Mailing address:
  • Phone: 601-572-5518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: