Provider Demographics
NPI:1104472653
Name:DALTON, SALLIE EVANS (MSN, APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SALLIE
Middle Name:EVANS
Last Name:DALTON
Suffix:
Gender:F
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 E MAIN ST STE 24
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-2308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1012 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-2308
Practice Address - Country:US
Practice Address - Phone:601-389-7889
Practice Address - Fax:601-533-2566
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903430363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1841933272OtherNPI 2
MS09876307Medicaid