Provider Demographics
NPI:1750901328
Name:DALTON, CHANDLER MIMS
Entity type:Individual
Prefix:
First Name:CHANDLER
Middle Name:MIMS
Last Name:DALTON
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 1:212 OLDE CASTLE LOOP
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-6012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1205 OFFICE PARK DR STE A
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-3546
Practice Address - Country:US
Practice Address - Phone:662-638-3412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-23
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901117163W00000X
MS904927363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse