Provider Demographics
NPI:1164815007
Name:BESSONETTE, ELLANIE L (AGACNP)
Entity Type:Individual
Prefix:
First Name:ELLANIE
Middle Name:L
Last Name:BESSONETTE
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-0490
Mailing Address - Country:US
Mailing Address - Phone:601-249-2701
Mailing Address - Fax:601-249-2195
Practice Address - Street 1:303 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2707
Practice Address - Country:US
Practice Address - Phone:601-249-1350
Practice Address - Fax:601-249-1339
Is Sole Proprietor?:No
Enumeration Date:2015-03-17
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR882864363L00000X
MS882864363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06079813Medicaid
MS406303YQVYMedicare PIN