Healthcare Provider Details

I. General information

NPI: 1205714870
Provider Name (Legal Business Name): MELINDA WYSSBROD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 PHILLIPS ROAD 216
LEXA AR
72355-8444
US

IV. Provider business mailing address

418 PHILLIPS ROAD 216
LEXA AR
72355-8444
US

V. Phone/Fax

Practice location:
  • Phone: 870-995-7807
  • Fax:
Mailing address:
  • Phone: 870-995-7807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number234694
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: