Provider Demographics
NPI:1851924013
Name:EZELLE, MELISSA ANN
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:EZELLE
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 1:23 CLINTON RD
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-9709
Mailing Address - Country:US
Mailing Address - Phone:601-519-2703
Mailing Address - Fax:
Practice Address - Street 1:6414 HWY 98 W, SUITE 120
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3940
Practice Address - Country:US
Practice Address - Phone:601-296-2833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904880363LF0000X
MSR871458163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse