Provider Demographics
NPI:1679241327
Name:CLANTON, ELISHIA
Entity Type:Individual
Prefix:
First Name:ELISHIA
Middle Name:
Last Name:CLANTON
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 1:1133 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-3409
Mailing Address - Country:US
Mailing Address - Phone:662-871-2966
Mailing Address - Fax:
Practice Address - Street 1:1133 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-3409
Practice Address - Country:US
Practice Address - Phone:662-678-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS526949174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty