Healthcare Provider Details

I. General information

NPI: 1760117022
Provider Name (Legal Business Name): VIRGINIA HENLEY MALONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIRGINIA JOYCE HENLEY NP

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR
JACKSON MS
39216-4606
US

IV. Provider business mailing address

969 LAKELAND DR
JACKSON MS
39216-4606
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number905454
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: