Healthcare Provider Details

I. General information

NPI: 1235581513
Provider Name (Legal Business Name): MELISSA COULSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 07/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 AVIGNON DR
RIDGELAND MS
39157-5120
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 601-605-6777
  • Fax: 601-607-1415
Mailing address:
  • Phone: 479-498-6700
  • Fax: 479-968-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901565
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: