Provider Demographics
NPI:1629103510
Name:MELTON, SANDRA FLINT
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:FLINT
Last Name:MELTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1241 S MOUND ST STE A
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4515
Mailing Address - Country:US
Mailing Address - Phone:662-226-3711
Mailing Address - Fax:
Practice Address - Street 1:1241 S MOUND ST STE A
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4515
Practice Address - Country:US
Practice Address - Phone:662-226-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR696943363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06777358Medicaid
MS500021513Medicare PIN