Basic Information
| Provider Information | |||||||||
| NPI: | 1851924013 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EZELLE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23 CLINTON RD | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394029709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015192703 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6414 HWY 98 W, SUITE 120 | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394023940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012962833 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2020 | ||||||||
| LastUpdateDate: | 10/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 904880 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | R871458 | MS | N | Nursing Service Providers | Registered Nurse |
No ID Information.