1548201403 NPI number — MELINDA BENNETT DELANCEY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548201403 NPI number — MELINDA BENNETT DELANCEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELANCEY
Provider First Name:
MELINDA
Provider Middle Name:
BENNETT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BENNETT
Provider Other First Name:
MELINDA
Provider Other Middle Name:
JORDAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548201403
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4358 LINCOLN ROAD EXT STE 20A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39402-3275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-589-9259
Provider Business Mailing Address Fax Number:
601-476-6404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4358 LINCOLN ROAD EXT STE 20A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HATTIESBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39402-3275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-589-9259
Provider Business Practice Location Address Fax Number:
601-476-6404
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  825528 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: R825528 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00123607 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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