Provider Demographics
NPI:1205104387
Name:YOUNG, DEALICE NIKITA (RN)
Entity type:Individual
Prefix:
First Name:DEALICE
Middle Name:NIKITA
Last Name:YOUNG
Suffix:
Gender:F
Credentials:RN
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 572
Mailing Address - Street 2:
Mailing Address - City:TCHULA
Mailing Address - State:MS
Mailing Address - Zip Code:39169-0572
Mailing Address - Country:US
Mailing Address - Phone:662-670-4197
Mailing Address - Fax:
Practice Address - Street 1:160 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:TCHULA
Practice Address - State:MS
Practice Address - Zip Code:39169
Practice Address - Country:US
Practice Address - Phone:662-670-4197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS894906163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health