Provider Demographics
NPI:1124691191
Name:MERCHANT, KIARA DIONTEA (NP)
Entity type:Individual
Prefix:MS
First Name:KIARA
Middle Name:DIONTEA
Last Name:MERCHANT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 S SECOND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-3941
Mailing Address - Country:US
Mailing Address - Phone:601-669-7357
Mailing Address - Fax:
Practice Address - Street 1:624 S SECOND ST
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-3941
Practice Address - Country:US
Practice Address - Phone:601-669-7357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901425163W00000X
MS904301363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty