Healthcare Provider Details

I. General information

NPI: 1760670970
Provider Name (Legal Business Name): MELISSA LEIGH SQUIRES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 24TH ST
FORT LEE VA
23801-1716
US

IV. Provider business mailing address

702 ENON CHURCH RD
CHESTER VA
23836-5912
US

V. Phone/Fax

Practice location:
  • Phone: 804-734-9942
  • Fax: 804-874-1008
Mailing address:
  • Phone: 804-536-4269
  • Fax: 866-616-0686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024167375
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: