MEDICARE: MELANIE G. PETCHAK NP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	APO3820	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336363845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELANIE G. PETCHAK NP-BC

Provider Business Mailing Address
First Line	:	1 SAINT MARY PL
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71101-4343
Country	:	US
Telephone Number	:	318-861-1671
Fax Number	:

Provider Business Practice Location Address
First Line	:	7611 SAINT VINCENT AVE
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-4231
Country	:	US
Telephone Number	:	318-861-1671
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	11/19/2024

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