Healthcare Provider Details

I. General information

NPI: 1770568230
Provider Name (Legal Business Name): MELISSA C DODSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 HARDY RD
MISSISSIPPI STATE MS
39762
US

IV. Provider business mailing address

PO BOX 6338
MISSISSIPPI STATE MS
39762
US

V. Phone/Fax

Practice location:
  • Phone: 662-325-2431
  • Fax: 662-325-8888
Mailing address:
  • Phone: 662-325-2431
  • Fax: 662-325-8888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR716928
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: