Healthcare Provider Details

I. General information

NPI: 1902210099
Provider Name (Legal Business Name): HEIDI MELLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8137 TATES CREEK RD
LEXINGTON KY
40515-8000
US

IV. Provider business mailing address

8137 TATES CREEK RD
LEXINGTON KY
40515-8000
US

V. Phone/Fax

Practice location:
  • Phone: 773-318-7841
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number005899
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: