Healthcare Provider Details

I. General information

NPI: 1811906423
Provider Name (Legal Business Name): MELISSA CATHERINE STATHAM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 5TH & TED STEVENS WAY
KOTZEBUE AK
99752-0043
US

IV. Provider business mailing address

PO BOX 1089
KOTZEBUE AK
99752-1089
US

V. Phone/Fax

Practice location:
  • Phone: 907-442-3321
  • Fax: 907-442-7250
Mailing address:
  • Phone: 907-442-2544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number922
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: