Healthcare Provider Details

I. General information

NPI: 1417811688
Provider Name (Legal Business Name): MELISSA LANDA GRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 HANGING OAK CIR
GULFPORT MS
39507-4413
US

IV. Provider business mailing address

6 HANGING OAK CIR
GULFPORT MS
39507-4413
US

V. Phone/Fax

Practice location:
  • Phone: 770-608-6111
  • Fax:
Mailing address:
  • Phone: 770-608-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number912598
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number912598
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: