Healthcare Provider Details

I. General information

NPI: 1619242443
Provider Name (Legal Business Name): MELISSA V LAYNE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 JUDGE GRESHAM RD SUITE B
GRAY TN
37615-6213
US

IV. Provider business mailing address

105 W STONE DR SUITE 6A
KINGSPORT TN
37660-3365
US

V. Phone/Fax

Practice location:
  • Phone: 423-477-2885
  • Fax: 423-477-0113
Mailing address:
  • Phone: 423-408-7220
  • Fax: 423-408-7405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16565
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: