Healthcare Provider Details

I. General information

NPI: 1356556260
Provider Name (Legal Business Name): MELISSA MARCUM LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 S BAILEY HAZEN RD
RYEGATE VT
05042
US

IV. Provider business mailing address

406 JEFFERSON RD
WHITEFIELD NH
03598-3125
US

V. Phone/Fax

Practice location:
  • Phone: 802-584-4679
  • Fax:
Mailing address:
  • Phone: 603-837-2388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number0250007641
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: