Healthcare Provider Details

I. General information

NPI: 1518493683
Provider Name (Legal Business Name): MELODY SUE KING APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELODY SUE BOURBEAU APRN

II. Dates (important events)

Enumeration Date: 05/10/2017
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 YOUNGS LANE
CINCINNATI OH
45245
US

IV. Provider business mailing address

822 YOUNGS LN
CINCINNATI OH
45245-2629
US

V. Phone/Fax

Practice location:
  • Phone: 513-516-1453
  • Fax:
Mailing address:
  • Phone: 513-516-1453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number020761
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number026761
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: