Healthcare Provider Details

I. General information

NPI: 1659077238
Provider Name (Legal Business Name): MELISSA MARIE BLACK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MELISSA MARIE POOLE

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 E MAIN ST
REXBURG ID
83440-2048
US

IV. Provider business mailing address

330 CIRCLE DR
RIGBY ID
83442-1375
US

V. Phone/Fax

Practice location:
  • Phone: 208-359-9811
  • Fax:
Mailing address:
  • Phone: 916-204-7056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number59333
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number59333
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number59333
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: