Healthcare Provider Details

I. General information

NPI: 1487908521
Provider Name (Legal Business Name): ABBY LYNN MELL ORT/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2012
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25841 HICKORY DR
FARMINGTON MO
63640-8102
US

IV. Provider business mailing address

25841 HICKORY DR
FARMINGTON MO
63640-2910
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-6566
  • Fax:
Mailing address:
  • Phone: 573-756-6566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number2010034176
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: