Healthcare Provider Details

I. General information

NPI: 1174358568
Provider Name (Legal Business Name): MELISSA LYNN MARINO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MAIN ST
GIDEON MO
63848-9253
US

IV. Provider business mailing address

1520 N DIVISION ST
BLYTHEVILLE AR
72315-1448
US

V. Phone/Fax

Practice location:
  • Phone: 870-838-7300
  • Fax:
Mailing address:
  • Phone: 870-838-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number39459
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number236794
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number39459
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2026012430
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: