Healthcare Provider Details

I. General information

NPI: 1154767309
Provider Name (Legal Business Name): MRS. TANYONISHA ROKAYE DALE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIKKI DALE

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 SHARON HILLS DR
JACKSON MS
39212-2234
US

IV. Provider business mailing address

411 SHARON HILLS DR
JACKSON MS
39212-2234
US

V. Phone/Fax

Practice location:
  • Phone: 601-918-6275
  • Fax:
Mailing address:
  • Phone: 601-918-6275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR856193
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR856193
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: