Healthcare Provider Details

I. General information

NPI: 1659527638
Provider Name (Legal Business Name): MELISSA DHEA ELMORE P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2008
Last Update Date: 08/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 KIMSEY LN
HENDERSON KY
42420-2665
US

IV. Provider business mailing address

851 KIMSEY LN
HENDERSON KY
42420-2665
US

V. Phone/Fax

Practice location:
  • Phone: 270-826-6436
  • Fax:
Mailing address:
  • Phone: 270-826-6436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA02266
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: