Healthcare Provider Details

I. General information

NPI: 1578488870
Provider Name (Legal Business Name): MALLIE HESTER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

874 BARNES CROSSING RD
TUPELO MS
38804-0909
US

IV. Provider business mailing address

874 BARNES CROSSING RD
TUPELO MS
38804-0909
US

V. Phone/Fax

Practice location:
  • Phone: 662-719-1020
  • Fax:
Mailing address:
  • Phone: 662-719-1020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2962
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: