Healthcare Provider Details

I. General information

NPI: 1275301335
Provider Name (Legal Business Name): KRISTINE ANN MELOCHE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTINE ANN HEUN

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5838 HARBOUR VIEW BLVD STE 240
SUFFOLK VA
23435-2663
US

IV. Provider business mailing address

5838 HARBOUR VIEW BLVD STE 240
SUFFOLK VA
23435-2663
US

V. Phone/Fax

Practice location:
  • Phone: 757-446-5600
  • Fax:
Mailing address:
  • Phone: 757-483-3030
  • Fax: 757-484-7239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110010201
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: