Healthcare Provider Details

I. General information

NPI: 1912350513
Provider Name (Legal Business Name): MELODEE B THACKER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 ROUTE US 60 W SUITE B
ASHLAND KY
41102
US

IV. Provider business mailing address

5900 ROUTE US 60 W SUITE B
ASHLAND KY
41102
US

V. Phone/Fax

Practice location:
  • Phone: 606-393-5586
  • Fax: 606-928-5547
Mailing address:
  • Phone: 606-393-5586
  • Fax: 606-928-5547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberAPRN.CNP.020075
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1145293
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: