Healthcare Provider Details

I. General information

NPI: 1316217953
Provider Name (Legal Business Name): MELISSA CORNETT BOCK APN; PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA D CORNETT-KEARNELY MSN

II. Dates (important events)

Enumeration Date: 01/12/2012
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2577 NE COURTNEY DR
BEND OR
97701-7638
US

IV. Provider business mailing address

2577 NE COURTNEY DR
BEND OR
97701-7638
US

V. Phone/Fax

Practice location:
  • Phone: 541-322-7521
  • Fax: 541-322-7565
Mailing address:
  • Phone: 541-322-7521
  • Fax: 541-322-7565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN # 1095982
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201601087
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201600791
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN# 3007370
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN18054
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN157517
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: