Healthcare Provider Details

I. General information

NPI: 1972110542
Provider Name (Legal Business Name): ROBYN RICHARDSON DALTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 AMERICAN WAY STE A
GRENADA MS
38901-2324
US

IV. Provider business mailing address

2817 AMERICAN WAY STE A
GRENADA MS
38901-2324
US

V. Phone/Fax

Practice location:
  • Phone: 662-442-2042
  • Fax: 662-442-2043
Mailing address:
  • Phone: 662-442-2042
  • Fax: 662-442-2043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number903971
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: