Healthcare Provider Details

I. General information

NPI: 1275158776
Provider Name (Legal Business Name): CHILDRENS HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 VAN DORN ST
GRENADA MS
38901-4738
US

IV. Provider business mailing address

340 VAN DORN ST
GRENADA MS
38901-4738
US

V. Phone/Fax

Practice location:
  • Phone: 662-226-0325
  • Fax: 662-226-0327
Mailing address:
  • Phone: 662-226-0325
  • Fax: 662-226-0327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MELANIE RENAE WILLIAMS
Title or Position: NURSE/OWNER
Credential:
Phone: 662-226-0325