Healthcare Provider Details

I. General information

NPI: 1043459696
Provider Name (Legal Business Name): MELISSA D MERRILL CNM, WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA VITEK

II. Dates (important events)

Enumeration Date: 02/05/2009
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 5TH AVE W
JEROME ID
83338-1825
US

IV. Provider business mailing address

132 5TH AVE W
JEROME ID
83338-1825
US

V. Phone/Fax

Practice location:
  • Phone: 208-324-5286
  • Fax: 208-324-9815
Mailing address:
  • Phone: 208-324-5286
  • Fax: 208-324-9815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberNP1172A
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number19862A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: