Healthcare Provider Details

I. General information

NPI: 1093763245
Provider Name (Legal Business Name): DANITA RONIQUE WEARY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 JEFFERSON DAVIS BLVD
NATCHEZ MS
39120-5104
US

IV. Provider business mailing address

PO BOX 17918
NATCHEZ MS
39122-7918
US

V. Phone/Fax

Practice location:
  • Phone: 601-442-5439
  • Fax: 601-442-3755
Mailing address:
  • Phone: 601-442-5439
  • Fax: 601-442-3755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18242
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: