Healthcare Provider Details

I. General information

NPI: 1922250364
Provider Name (Legal Business Name): MELISSA SAMPLE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 01/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WASO
CHILOQUIN OR
97624
US

IV. Provider business mailing address

2074 S 6TH ST
KLAMATH FALLS OR
97601-3372
US

V. Phone/Fax

Practice location:
  • Phone: 541-880-2011
  • Fax: 541-783-3273
Mailing address:
  • Phone: 541-880-2011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number099000635RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200850150NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: