Healthcare Provider Details

I. General information

NPI: 1629103510
Provider Name (Legal Business Name): SANDRA FLINT MELTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 S MOUND ST STE A
GRENADA MS
38901-4515
US

IV. Provider business mailing address

1241 S MOUND ST STE A
GRENADA MS
38901-4515
US

V. Phone/Fax

Practice location:
  • Phone: 662-226-3711
  • Fax:
Mailing address:
  • Phone: 662-226-3711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR696943
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: