Healthcare Provider Details

I. General information

NPI: 1477097970
Provider Name (Legal Business Name): MELODIE ELLIS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2016
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-8074
  • Fax: 859-301-4945
Mailing address:
  • Phone: 859-344-5555
  • Fax: 859-212-4357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3010910
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: