Basic Information
| Provider Information | |||||||||
| NPI: | 1518167832 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYESS | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | OKJA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 196 OLD HIGHWAY 43 | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390478568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019545565 | ||||||||
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| Practice Location | |||||||||
| Address1: | 151 E METRO DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392324402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019923288 | ||||||||
| FaxNumber: | 6019923188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2007 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20104 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04139568 | 05 | MS | MEDICAID |