Healthcare Provider Details

I. General information

NPI: 1578093704
Provider Name (Legal Business Name): MELINDA A WEISENBERGER AT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 06/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 W NORTHSIDE DRIVE
CLINTON MS
39056
US

IV. Provider business mailing address

4600 W NORTHSIDE DR
CLINTON MS
39056-9699
US

V. Phone/Fax

Practice location:
  • Phone: 601-668-6064
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0203
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: