Healthcare Provider Details

I. General information

NPI: 1033693866
Provider Name (Legal Business Name): MELODIE CAROL VICK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NORTHSIDE DR
NEWTON MS
39345-2361
US

IV. Provider business mailing address

700 NORTHSIDE DR
NEWTON MS
39345-2361
US

V. Phone/Fax

Practice location:
  • Phone: 601-683-4300
  • Fax: 601-683-4303
Mailing address:
  • Phone: 601-683-4300
  • Fax: 601-683-4303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902713
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number902713
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: