Provider Demographics
NPI:1174309819
Name:DELTA PHOENIX MEDICAL CONSULTING
Entity type:Organization
Organization Name:DELTA PHOENIX MEDICAL CONSULTING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:STANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:662-231-8436
Mailing Address - Street 1:940 CHURCH RD W STE A2
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9611
Mailing Address - Country:US
Mailing Address - Phone:662-231-8436
Mailing Address - Fax:
Practice Address - Street 1:940 CHURCH RD W STE A2
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9611
Practice Address - Country:US
Practice Address - Phone:662-231-8436
Practice Address - Fax:662-536-6640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty