Healthcare Provider Details

I. General information

NPI: 1639042401
Provider Name (Legal Business Name): MELINDA RENEE CAUDILL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2025
Last Update Date: 10/24/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 BLUE JAY CT
VINE GROVE KY
40175-6289
US

IV. Provider business mailing address

80 BLUE JAY CT
VINE GROVE KY
40175-6289
US

V. Phone/Fax

Practice location:
  • Phone: 606-776-2536
  • Fax:
Mailing address:
  • Phone: 606-776-2536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: