Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 15983 | MS |
NPI | 1174517007 |
---|---|
Provider Name | Melissa B Roberts |
First Address | Jackson, MS 39225-2505 |
Second Address | Hattiesburg, MS 39402-1308 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00123317 | (05) | MS |
H92161 | (02) |