Healthcare Provider Details

I. General information

NPI: 1013243104
Provider Name (Legal Business Name): REBECCA ANN MELANCON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2009
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 N ACADIA RD
THIBODAUX LA
70301-4823
US

IV. Provider business mailing address

412 WINDWARD DR
HOUMA LA
70360-5004
US

V. Phone/Fax

Practice location:
  • Phone: 985-447-5500
  • Fax:
Mailing address:
  • Phone: 985-226-8182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License NumberAP03672
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: