Healthcare Provider Details

I. General information

NPI: 1679051106
Provider Name (Legal Business Name): MELISSA JEAN KISTNER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELISSA JEAN GRUBBS

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 INNOVATION DR STE 102
CHESAPEAKE VA
23320-3866
US

IV. Provider business mailing address

615 ELSINORE PL STE 200
CINCINNATI OH
45202-1457
US

V. Phone/Fax

Practice location:
  • Phone: 833-510-4357
  • Fax:
Mailing address:
  • Phone: 513-834-7063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024176462
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: