Healthcare Provider Details

I. General information

NPI: 1487952966
Provider Name (Legal Business Name): MELISSA RENEE LAYCOCK APRN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2011
Last Update Date: 03/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 NE 96TH ST
LIBERTY MO
64068-1348
US

IV. Provider business mailing address

1504 NE 96TH ST
LIBERTY MO
64068-1348
US

V. Phone/Fax

Practice location:
  • Phone: 816-415-2233
  • Fax:
Mailing address:
  • Phone: 816-415-2233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2011006215
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: